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HEALTH 
SCIENCES 
LIBRARY 


^J^.    cU.    S/-    "^ 

/ 


HANDBOOK 


OF 


GYi\^COLOGICAL   OPERATIONS^ 


ALBAIS"  H.  G.  DOEAX,  F.E.C.S. 

SURGEON  TO  OUT-PATIEXTS,   SAMARITAN   FREE  HOSPITAL  FOR  WOMEN   AND  CHILDREN, 

LONDON 

Author  of  "  Clinical  and  Pathological  Observations  on  Tumour    of  the  Ovary, 
Fallopian  Tube,  and  Broad  Ligament  " 


WITH     ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTOK,     SOX    &    CO. 

1012,  WALXUT  STREET 
1887 


1  0^ 


PEEFACE. 


In  tliis  handbook  I  have  endeavoured  to  draw  a  line  between 
surgical  operations  on  the  female  organs  and  proceedings  of  a 
more  or  less  purely  obstetrical  or  therapeutical  character  fully 
described  in  current  works  on  midwifery  and  diseases  of  women. 
This  manual  is  devoted  to  true  surgery,  according  to  the  usual 
signification  of  the  term,  although  for  given  reasons  certain 
operations  mainly  obstetrical  in  nature  have  been  introduced. 
Much  importance  is  attached  to  the  anatomy  and  methods  of 
examination  of  the  pelvic  organs  and  to  a  proper  selection  of 
instruments.  A  sound  knowledge  of  these  subjects  will  greatly 
lighten  the  task  of  the  operator. 

Ovariotomy  has  been  chosen  as  the  type  of  abdominal  section, 
and  several  chapters  are  devoted  to  the  steps  of  that  operation 
and  to  after-treatment.  In  preparing  those  chapters,  I  have 
availed  myself  of  a  long  series  of  notes  of  nearly  nine  hundred 
abdominal  operations  at  which  I  have  assisted,  including  cases 
under  my  own  care.  The  success  of  surgery  of  this  class 
depends  largely  upon  matters  of  detail  readily  recorded  by  the 
experienced,  and  thus  transmissible  through  literary  channels  to 
those  who  seek  for  instruction.  On  the  other  hand,  the  steps  of 
plastic  procedures  cannot  be  easily  taught  by  printed  directions  ; 
they  may,  however,  be  fairly  explained  by  diagrams,  and  the 
success  of  operations  of  this  kind  depends  upon  other  factors 
besides  manual  dexterity.  I  have  said  little  about  the  results  of 
major  operations,  since  long  tables  of  statistics  prepared  by 
experienced  operators  are  unreliable  guides  to  those  who  have  few 
opportunities  of  performing  abdominal  section.     My  friend  Dr. 


iv  PREFACE. 

Steavenson  has  kindly  written  a  chapter  on  electrical  apx^aratus, 
and  added  passages  ontlie  same  subject  to  other  chapters.  We 
liave  excluded  any  mention  of  the  employment  of  electrolysis 
for  the  cm-e  of  fibroid  disease,  as  this  important  method,  though 
apparentl}'  full  of  promise,  has  not  been  as  yet  completely 
established  ;  nor  is  the  method  of  its  application  strictly  within 
the  limits  of  what  is  understood  by  a  surgical  operation. 

]\Iany  of  the  illustrations  are  original,  and  have  been  drawn 
by  Mr.  Lewin  from  fresh  specimens  and  from  preparations  in 
the  museum  of  the  Eoyal  College  of  Surgeons.  Figs.  92,  94, 
98,  99,  102  to  107,  109,  114,  115,  117,  118,  127,  and  150  are 
taken  from  my  own  sketches,  and  several  illustrations  originally 
appeared  in  my  Clinical  and  Pathological  Ohsenrttions  on 
Tumours  of  the  Ovary,  Fallopian  Tube,  and  Broad  Ligament. 
Figs.  70,  71,  and  72  were  drawn  by  Mr.  Leonard  Marks, 
late  of  St.  Bartholomew's  Hospital,  My  thanks  are  due  to 
Su'  Spencer  "Wells,  Drs.  Emmet,  Matthews  Duncan,  Savage, 
and  Bantock,  and  Mr.  Mayo  Robson  for  permission  to 
reproduce  some  woodcuts  from  their  own  works.  The  sketches 
of  instruments  were  kindly  lent  by  Messrs.  Krohne  & 
Sesemann,  the  di-awings  of  galvanic  apparatus  by  Messrs. 
Coxeter  &  Son  and  Ai"nold  &  Sons. 

The  absence  of  a  satisfactory  system  of  nomenclature  has 
given  me  great  trouble,  and  I  have  been  compelled,  by  custom, 
to  employ  many  words  and  phrases  to  which  I  object.  As 
regards  proper  names  applied  to  operations  and  instruments, 
I  cannot  guarantee  priority  to  any  particular  operator  or 
inventor.  Certain  grammatical  questions  relating  to  terms 
used  by  surgeons  and  gynaecologists  are  briefly  discussed  in 
footnotes.  For  the  orthography  of  many  words,  such  as 
Ccesarean,  hilum,  aneurysm,  siphon,  and  perineorrhaphy,  I  have 
relied  upon  Hyrtl's  Onomatologia  Anatomica,  and  on  the 
authority  of  my  friend  and  former  colleague  Dr.  Alexander 
Henry,  and  other  classical  scholars. 

Classification  of  the  subjects  of  this  work  has  proved  difficult, 
as  every  surgical  operation  depends  more  or  less  on  anatomy 
and  also  on  pathology.  An  arrangement  based  on  piu'ely 
surgical  grounds  thereby  becomes  an  impossibility,  nor  can 
any  system  be  simultaneously  consistent  with  anatomical  and 


TKEFACE. 


with  pathological  requirements.  Practical  considerations  being 
here  of  the  first  importance,  man}^  details  have  been  repeated 
in  chapters  on  different  operations.  Owing  to  the  impossibility 
of  this  kind  of  repetition  beyond  a  certain  point,  and  to  the 
impediments  in  the  way  of  a  system  of  classification  allowing 
every  facility  of  reference,  I  have  made  the  index  as  copious 
as  possible. 

I  here  take  the  oj)portunity  of  thanking  ni}^  colleagues, 
especially  Drs.  Bantock  and  Percy  Boulton  for  kindly  revising 
certain  descriptive  portions  of  the  handbook,  relating  to 
abdominal  sections  and  plastic  operations. 


9,  GuAxviiJ.E  Place,  PoKTiMAN  SguAiiM, 
July,  1887. 


contexts: 


CHAPTER  I. 

1'A(;k 

Till.' Surii;i<'al  Anatomy  of  tlie  Female  Organ.s  ...  ...  ...  ...         1 


CHAPTER  II. 

Jlethoils  of  Pelvic  Ex]j] oration  ..  '45 

CHAPTER  III. 

Iiistrnineiils  ami  Ap])]ia]H;(^K     ...  ...  ...  ...  ...  ...  ...        82 

CHAPTER  IV. 

Iiistnniieiits  ami  Aii]iliaiices  (c'o/'iiii/iHCf?)         ...         ...  ...  ...  ...     1-^ 

CHAPTER  V. 

Electiiral  A]i]iaratns  nseil  in  (iyiiaicologioal  Sui'gevy  ...  ...  ...     141 

CHAPTER  A'l. 

Suvgieal  PatlKjlogy  of  Cy.stieaml  Allied  Di.sea.ses  of  thu  Uteriur  Apiieml- 
ages — Examination  of  Ahilomiiial  Tumours  ...         ...  ...  ...     loS 

CHAPTER  VII. 

The  Operation  of  Ovariotomy  ..  ...         ...         ...  ..  ...  ..      1.S2 

CHAPTER  VIII. 

The  Ojieration  of  Ovariotomy  {r.oiduincd)        ...  ..  ...  ...  ...     -J.!') 


viii  •  rONTKNTS. 

CHAPTER    IX. 

VMiK 

(Jvariotiiiiiy:   Aftci-tri'atiiii'iit  .iiiil  AlanaLft'iiieut  of  Cniiniliratioiis  ...     24:5 

CHAITER  X. 
Oi>i«ln«rcct«iiiiy  ami  Allii'il  Oiiciatidiis ^'^ 

CHAl'TKK   XI. 

Sii|.ia-\'a^niial  Hysr.Tcrtoiiiy— Ojieratioiis  uii  Filnoid  Tuiiiiuus  ami  I'olyjii     28H 

CHAITEK  XII. 

Vai^inal  E.xtirpatioii   of  tin-  Uterus— Aiiiputatioii   of  the  Cfivix— Traehc- 

lonliaiihy      ...         ...         •■  ••  ••  •■  ••  •■  ••       '^1' 

CHAITER    XIII. 
OiH-iativc  Ticatiiiciit  of  E.xtra-l'tciiiic  rrcifuamy 350 

CHAPTER  XIV. 
Cii'.sarcaii  Scctinn  ami  i'mni's  Opeiatioii  ...  3H9 

CHAPTER  XV. 

OjuTatidiis  Jul-  tlic  Rcjiaii-  of    Ruiitiiicil    I'l'iiiu'uui  ami   tor  flic    Rclirf  of 

Pidlapsus  rtcri        ...  ...  ...  ..  ...  ...  ..  ...     -ifij 

CHAPTER  XVI. 

Operations  for  tlie  Relief  of  Uiiiiary  Fistula-,  Reeto-^'ajiinal  Fistuhe  and 

Eiti>liia  Vesiea-         ...  ...  ...  ...  ...  ...  ...  ...      418 

CHAPTER  XVII. 
Operations  on  tlio  N'agiiia.  Vulvar  Stiiietures,  ami  I'retliva  ...      458 

A  i>i>i;Ni>r.M   UN  l)i;,\iNA(;i:      474 


LIST    OF   ILLUSTEATIOJ^S. 


FIG. 

1.  The  External  Parts  of  an  Adult  Virgin 

2.  The  Vulva  in  CMldhood     

3.  I.   LahiefovTR  Jljmen  (Tarclieu).     II.   Lingulate  Hymen  (Z>o7i 

4.  Hymen  Biseptus 

5.  Vulva  laid  open  to  display  the  Vestibule... 

6.  Vertical  Section  of  the  Pelvic  Viscera  (after  Foster 

7.  Broad  Ligament  Cyst  above  the  Tube 

8 .  Diagram  of  the  Uterine  Appendages  {Henlc) 

9.  Accessory  Fimbriee  and  Ostium  on  a  Fallopian  Tube  [Author] 

10.  Right  Half  of  the  Bladder  and  Uterus,  with  Part  of  Vagina 

11.  Normal  Relations  of  Cervix,  Ureters,  and  Urethra  {Hegar  and 

bach) 

12.  Arteries  of  Internal  Female  Organs  [after  Hyrtl) 

13.  Bimanual  Examination  [Sions) 

14.  Fergusson's  Speculum 

15.  16.  Speculum- Forceps 

17.  Playfair's  Probe 

18.  Sims'  Speculum 

19.  Neugebauer's  Speculum 

20.  Barnes'  Crescent  Speculum... 

21.  Cusco's  Bivalve  Speculum  ... 

22.  Sound 

23.  Volsella  

24.  Tent  Introducer 

25.  Wristlets  or  Handcuffs 

26.  Thigh-Belt 

27.  Scissors  for  Ovariotomy,  bent  on  the  Flat 

28.  Koeberle's  Pressure-Forceps 

29.  Wells'  Pressure-Forceps  [old form) 

30.  Wells'  Pressure-Forceps  {neivform) 

31.  Tait's  Pressure-Forceps 

32.  T-bladed  Pressure-Forceps  ... 

33.  Adams'  Peritoneum-Hook  ... 
54.  Stanley's  Director     ... 

35.  Wells'  Ovariotomy-Trocar  ... 

36.  Tait's  Ovariotomy-Trocar    ... 

37.  Wells'  Tapping-Trocar 

38.  Volsella  for  Ovariotomy 

39.  Nekton's  Volsella    ..." 


Kalten- 


P.A.GE 

2 
3 


10 
14 
22 
23 
25 
29 

32 

42 

55 

58 

60 

61 

62 

65 

66 

67 

73 

78 

SO 

86 

86 

92 

95 

96 

97 

99 

100 

101 

102 

102 

104 

105 

106 

107 


LIST    OF    ILLUSTRATIONS. 


PAOE 

109 

111 

112 
112 
113 
114 
114 


FIG. 

40.  Large  Pressure-Forceps 

41.  T-blailcd  ami  Angle-Bladed  Large  Pressure-Forceps      

42.  "Wells'  Large  Clanip-Forceps  

43.  Wells' Small  Clamp-Forceps  

44.  Pedicle-Xeedle  

45.  "Wells' Blunt-ended  Pedicle-Needle  

46.  Long  Pedicle-Xeedle  

47.  Needle-holder  ••  H^ 

48.  Needle  for  Ovariotomy        116 

49.  Hagedorn's  Needles ...         ...         ...         ...         ■■.         •■•         •••         •••  117 

50.  Ettects  of  Suture  made  by  Ordinary  and  by  Hagedorn's  Needles         ..  118 

51.  Hagedorn's  Needle-bolder  ...         ...         ...         ...         ■■•         ••  ••  119 

52.  Koeberle's  Serre-Noeud        123 

53.  Pedicle-Pins 124 

54.  Koeberle's  Drainage-Tube 125 

55.  Keith's  Drainage-Tube        126 

56.  Clover's  Crutch         ■ 132 

57.  Thornton's  lee-cap  ...         ...         ...         ...  ...         ...         ...         ■.  133 

58.  Leiter's  Cap 135 

59.  Leiter's  Temperature  Regulator     ...         ...         ...         ...         ...         ...  136 

60.  Leiter's  Temperature  Regulator  :  How  to  Bend  it         137 

61.  Leiter's  Temperature  Regulator  :   How  to  Straighten  it  137 

62.  Clay's  Insufflator      138 

63.  Kabiersky's  Insufflator        139 

64.  Nozzles  for  Kabiersky's  Insufflator  139 

65.  Bichromate  of  Potash  Galvano-cautery  Battery  .. .         ...         ...         ...  144 

66.  Bunsen's  Battery 147 

67.  Grove's  Battery  with  "Wire  Ecraseur         ...         ...         ...         ...         ..  148 

68.  Cautcrs  and  Ecraseur  ...         ...         ...         ...         .  ...         ...  151 

69.  Firm  Platinum  Knife  151 

70.  Galvanic  Ecraseur    ...         ...         ...         ...         ...         ..  ...  .  152 

71.  Side  View  of  same    ...         ...         ...         ...         ...         ...         ...         ...  153 

72.  Two  Clip-Handles 153 

73.  Small  Electric  Lamp  ...         ...         ...         ...         ...         ...         ...  156 

74.  Electric  Lamp  fitted  to  a  Fergusson's  Speculum  157 

75.  Structures  in  and  adjacent  to  the  Broad  Ligament  (Author)  ...  159 

76.  A  Small  Multilocular  Cyst  (^«7/«or)         159 

77.  Dermoid  Ovarian  Tumour,  bearing  Teeth  and  Bone  (Author)  ...  160- 

78.  Dermoid  Ovarian  Tumour,    consisting  of  Three  Lofuli  of  Irregular 

Foi-m      • 160 

79.  Papillomatous  Cystic  Tumour  of  Ovary  (^M</tor)  ...         ...         ...  161 

80.  Papillomatous  Disease  of  the  Broad  Ligaments  ...         ...         ...  162 

81.  Ovary  covered  with  Papillomata    ...         ...         ...         ...         ...         ...  162 

82.  Simple  Broatl  Ligament,  or  "  Parovarian  Cyst "  ...         ...         ...  163 

83.  Dissection  of  Broad  Ligament,  to  show  its  relations  to  two  cysts        ...  164 

84.  Papilloma  of  the  Fallopian  Tube  (.^H</wr)  ...         ...         ...         ...  16S 

85.  A  small  Sarcomatous  Ovary  (Author)       ...         ...         ...         ...         ...  165 

86.  A  Twisted  Pedicle 176 

87.  Dilated  Vein  from  a  Twi.sted  Pedicle        ...         ...         ...         ...         ...  177 

88.  Ovarian  Cyst  suppurating  after  Prolonged  Drainage     ...         ...         ...  179 


LIST    OF    ILLUSTRATIONS. 


SI 


FIG. 
89. 
90. 
91. 
92. 
93. 
94. 
95. 
96. 

97. 


100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 
131. 
132. 
183. 
134. 
135. 
136. 
137. 


PAGE 

Ovarian  Cyst  unaffected  bj^  Prolonged  Drainage  ...  ...  ...  180 

Ovarian  Disease  in  a  Still-born  Child     ...         ...         ...  ...  ...  183 

Stump  of  an  Ovarian  Pedicle  One  Week  after  Operation  ...  ...  186 

Mechanism  of  Splitting  of  the  Pedicle   ...  ...  ...  ...  ...  187 

Ovariotomy  :  The  Waterproof  Sheet  applied  to  the  Abdomen  ( JJ'clls)  198 

Position  of  Tables,  Operator,  etc.,  during  Ovariotomy  ...  ...  200 

Ovariotomy  :  The  Trocar  plunged  into  the  Cyst  (  JVells)  ...  ..  208 

Ovariotomy  :  Extraction  of  the  Cyst  through  the  Abdominal  Wound 

(Wells) 208 

Ovariotomy:  Breaking  down  Solid  Matter  (a/'^er  fS'a'Da^e)  ...  ...  210 

A  Long  Pedicle      ...         ...         ...  ...         ...         ...  ...  ...  215 

A  Short,  Broad  Pedicle      216 

Dermoid  Cyst  separated  from  its  Pedicle  (^«<^or)       ...  ...  ...  218 

Stump  of  the  Pedicle  from  the  same  case  ...  ...  ...  ...  218 

Ligature  of  the  Pedicle  :  Transfixion  with  the  Needle  ...  ...  220 

Ligature  of  the  Pedicle  :  Thread  Passed  through  Loop  ...  ...  220 

Ligature  of  the  Pedicle  :  Threads  Crossed         ...  ...  ...  ...  221 

Ligature  of  the  Pedicle  :  Double  Transfixion  ...         ...  ...  ...  223 

Ligature  of  the  Pedicle  :  Double  Transfixion,  threads  tied  ...  ...  223 

Cyst  secured  by  Sutures  to  Abdominal  Wound  ...  ...  ...  229 

Ovariotomy:  Introduction  of  Sutures  (a/<er  >S'ft'ya^e)  ...  ...  234 

The  Sutures  in  the  Abdominal  Wound  ...         ...  ...  ...  235 

Hernia  of  the  Cicatrix  of  an  Abdominal  Wound         ...  ...  ...  254 

A  n  Obstructed  Fallopian  Tube    ...         ...         ...         ...  ...  ...  274 

Fallopian  Tube  forming  a  Large  Cystic  Tumour  ...  ...  ...  275 

Ovary  adherent  to  the  Great  Omentum  ...         ...  ...  ...  279 

Oophorectomy  :  Transfixion  of  the  Pedicle       ...         ...  ...  ...  281 

Fibroid  Uterus  :  Altered  Relations  of  Appendages      ...  ...  ...  291 

Fibroid  Uterus  with  Interstitial  Growths  ...         ...  ...  ...  293 

Fibroid  Uterus  :  Pedicle  very  broad       ...  ...  ...  ...  ...  294 

Pedicle  of  Uterine  Fibroid  secured  by  Serre-nceud  and  Pins  ...  ...  296 

Uterus  with  Large  Fibroid  Outgrowth 303 

Kidd's  Volsella     ...  ...         ...         ...  ...  ...  ...  ...  .309 

Sims' Guarded  Tumour-Hook      ...         ...         ...  ...  ...  ...  309 

Sims'  Tampon-Screw         ...         ...         ...         ...         ...  ...  ...  310 

Uterine  Polypus-Forceps  ...         ...         ...  ...  ...  ...  314 

Curved  Ecraseur     ...         ...         ...  ...         ...         ...  ...  ...  329 

Zinc  Electrode  for  the  Decomposition  of  Cancerous  Tissue  ...  ...  333 

Short  Speculum  for  Trachelorrhaphy  (^oi(Zto'/i)  ...  ...  ...  341 

Lacerated  Cervix  after  Denudation         ...         ...         ...  ...  ...  342 

Lacerated  Cervix  after  Denudation  (^»M?ic^)     ...  ...  ...  ...  343 

Cicatricial  Hypertrophy  after  Laceration  (ii'?H??ie<)       ...  ...  ...  347 

Horizontal  Plane  of  Cervix  from  same  case  as  Fig.  129  [Emmet)  ...  347 

Cicatricial  Plug  in  a  Lacerated  Cervix '(^?)i?nc<)  ...  ...  ...  348 

Bifid  Laceration  of  the  Cervix  (^??i7;ic^)  ...  ...  ...  ...  349 

Gestation  in  Outer  Portion  of  Left  Fallopian  Tube      ...  ...  ...  351 

Tubal  Gestation,  Sac  in  Douglas's  Pouch  ...  ...  ...  ...  355 

Tubal  Pregnancy    ...         ...         ...  ...         ...         ...  ...  ...  3(30 

Tubo-Uterine,  or  "Interstitial"  Pregnancy     ...  ...  ...  ...  361 

Diagram  of  Uterine  Wound  in  Sanger's  Ceesarean  Section  373 


xii  LIST    OF    ILLUSTRATIONS. 


PARK 


FIG. 

138.  Diagram  representing  Application  of  Sutures  in  same  Operation      ...  374 

139.  Operation  for  Ruptured  Perineum  :  The  Raw  Surface  [Bantock)       ...  393 

140.  Operation  for  Ruptured  rerineuui  :  The  Anal  Sutures  (i?(Mi):ocl-)      ...  395 

141.  Operation  for  Ruptured  Perineum  :  The  Perineal  Sutures  (^«?i<oc^-)...  397 

142.  Operation   for  Ruptured   Perineum  :    Sutures   applied   to    Vaginal 

Mucous  Membrane  (^fmto'A;)             397 

143.  Operation  for  Ruptured  Perineum  :  Piu'se-string  Operation  {Boulton)  401 

144.  Ennnet's  Elytrorrhaphy  :  The  Three  Freshened  Surfaces        410 

145.  Emmet's  Elytrorrhaphy  :  The  Folds  in  the  Vaginal  Wall  Vivified 

and  Sutured      410 

146.  Elastic  Gum  Vaginal  Dilator       .425 

147.  Sponge-holder         ...         ...         ...         ...         .••         •••         •••         •••  42/ 

148.  Vesico-Vaginal  Fistula  Knives 427 

149.  A^esieo-Vaginal  Fistula  Needle  (i?ouZto)i)          429 

150.  Operation  for  Vesico-Vaginal  Fistula  :  Introduction  of  Suture         ...  430 

151.  Blunt-Hook  for  same  Operation  (^oi«Zto'/i)         430 

152.  The  Sutures  after  Introduction  (/S'mojt) 431 

153.  S-headed  Suture-Twister 432 

154.  The  same  in  use      ...         ...         ...         ...         ...         ...         •••         •••  432 

155.  The  "Wires  Twisted  and  Secured 432 

156.  Self-Retaining  Catheter  (^OitZ^oji)           433 

157.  Atresia  of  Urethra  between  two  Fistulas  (iS'mo)i)          438 

158.  The  same  :  First  Operation  for  its  Relief  (^imoji)         439 

159.  Vesico-Uterine  Fistula  { r/wHWYs)            441 

160.  Colpocleisis  (,S'mo;i)           444 

161.  Wood's   Operation   for   Ectopia  Vesicre  :    Flaps  Marked  Out  {3Iayo 

Rohson) 452 

162.  Wood's  Operation  for  Ectopia  Vesicre:  Flaps  Stitched  (irf.)          ...  454 

163.  Wood's  Operation  for  Ectopia  Vesica;:  Retraction  of  Flaps  (iV?.)  ...  455 

164.  Wood's  Operation  for  Ectopia  Vesica  :  Result  of  Second  Operation(2VZ.  )456 

165.  Atresia  Vaginte,  with  Patulous  Hymen  [Matthexvs  Duncan) 461 

166.  Cauters  for  Treatment  of  Urethral  Caruncle     .  .         ...         ...           ..  471 

167.  Simon's  Dilator     472 


ERRATA,  Etc. 

Page  27,  line  15. — For  "a  little  over  two  inches"  substitute  "a  little  under  two 

inches." 
.,      106,  note. — For  "page  78  "  substitute  ' '  page  76." 
,,      132,  line  10.  add  "In    some  cases  it  will  be  found  more  convenient   to 

adjust  the  bands  below  the  knee." 


A   HANDBOOK   OF 

GYNAECOLOGICAL    OPERATIONS. 


CHAPTEE  I. 

THE    SURGICAL    ANATOMY    OF   THE   FEMALE    ORGAXS. 

A  CONSIDERABLE  portion  of  the  earlier  pages  of  this  work  will, 
from  motives  of  principle  and  convenience,  be  devoted  to  surgical 
anatomy.  The  principle  that  the  operator  should  be  acquainted 
with  anatomy  needs  no  support  from  argument.  Every  opera- 
tion involves  anatomical  considerations.  The  scope  of  this  work 
is  confined  to  a  limited  anatomical  area,  but  includes  descrip- 
tions of  a  relatively  large  number  of  operations.  Hence  a 
preliminary  sketch  of  the  anatomy  of  that  area  will  save  much 
unnecessary  repetition.  The  term  "  surgical  anatomy  "  is  here 
employed  in  its  conventional  sense.  It  is  an  ill-defined  but 
useful  expression,  intended  to  designate  as  much  anatomical 
knowledge  as  is  likely  to  prove  of  practical  service  to  the 
surgeon.  I  shall  at  once  proceed  to  describe  the  organs  and 
structures  in  the  order  adopted  by  most  contemporary  writers. 
Labia  Major  a. — The  labia  majora  are  a  pair  of  large  folds 
of  skin,  including  the  dartos,  fat,  and  connective  tissue.  They 
are  externally  and,  to  a  less  extent,  internally  covered  with 
hair.  The  labia  unite  at  the  symphysis  pubis,  but  it  is  a  mis- 
take to  suppose  that  they  meet  posteriorly.  Fig.  1  shows  that 
they  are  separate  in  the  adult ;  in  Fig.  2  they  are  seen  to  end 
behind  the  deeper  structures  of  the  vulva  as  two  elevated  pads 
of  integument.  This  is  the  normal  condition  in  very  young 
subjects.  Dubois  and  Pajot,  and  Matthews  Duncan  have  ex- 
posed the  prevalent  fallacy  about  the  posterior  portions  of  the 


2  THK    fel'KGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

labia.  In  plastic  operations  in  their  vicinity,  there  is  no  neces- 
sity to  atteni]it  to  unite  them.  In  the  space  between  the  ends  of 
the  labia  and  the  hymen  lies  the  anterior  part  of  the  perineum ; 
its  prominent  anteri<^r  limit  forms  the  "  posterior  fourchette " 


Fiii.  1.— Tni:  Exteuxal  Pakts  of  ax  Adult  Yirgix. 

The  labia  inajoia  arc  seen  to  end  posteriorlj'^  without  uniting.  The  posteiior 
fourcliette  is  hut  slightly  marked  ;  the  integument  -which  forms  it  is  wrinkled. 
The  true  relations  of  the  labia  minora  to  the  clitoris  and  hymen  are  indicated. 
The  meatus  urinarius  forms  a  narrow  slit  curved  with  its  convexity  forwards. 
The  parts  are  displaj'ed  as  seen  in  life  when  the  labia  are  artificially  separated. 
{Museum  R.C.S.,  Physiological  Series,  Xo.  2,844.) 

or  "frainulum."  On  everting  tlie  structures  on  each  side,  a 
crescentic  depression,  with  its  cornua  pointing  forwards,  will 
appear  between  the  fourchette  and  the  hjinen.    This  depression 


LABIA    MAJORA LABIA    MINORA.  6 

is  the  "  fossa  navicularis."  It  is  the  integument  in  the  middle 
line  of  the  fossa,  and  not  the  posterior  fourchette,  that  is  so  fre- 
quently torn  at  the  first  labour.  After  that  event,  the  posterior 
extremities  of  the  labia  majora  undergo  more  or  less  atrophy, 
and  the  relations  of  the  fourchette  and  the  structures  in  front 
of  it  can  no  longer  be  defined  with  precision. 

Labia  Minora  or  Nymphae. — These  terms  are  given  to 
two  thin,  hairless,  cutaneous  folds,  bright  red  in  colour,  and 
concealed  by  the  labia  majora  in  most  virgins.  In  multiparse 
they  become  flaccid  and  elongated,  and  project  beyond  the 
greater  labia.  Their  outer  surfaces  then  assume  the  characters 
of  dark,  dry  skin.  The  free  border  of  each  nympha  terminates 
anteriorly,  not  in  the  prej)uce  as  generally  supposed,  but  in 
the  frtenum  of  the  clitoris  (Figs.  1,  2,  5).     On  the  other  hand, 


Fig.  2. — The  Vulva  ix  Childhood. 

The  true  posterior  relations  of  the  external  labia  and  the  relations  of  the 
nymphfe  to  the  clitoris  are  demonstrated,  as  in  Fig.  1.  The  urethra  has  been 
dilated  artificially.     {Micscum  R.C'.S.,  Physiological  Scries,  Xo.  2,841a.) 

the  prepuce  is  continued  laterally  on  to  the  outer  surfaces  of 
the  labia  minora,  with  which  it  blends.  I  have  repeatedly 
verified  the  above  relations  by  examination  of  live  subjects. 
Posteriorly,  the  labia  minora  are  lost  on  the  integuments  of 
the  vulva,  rather  than  on  the  inner  side  of  the  greater  labia,  as 
sometimes  described.  The  inner  surfaces  of  the  labia  minora 
are  well  supplied  with  sebaceous  glands,  and  generally  midero-o 
dm-ing  pregnancy  a  purple  or  lilac  discoloration,  in  which  the 
vaginal  mucous  membrane  shares.  A  second  labium  minus 
sometimes  exists ;  it  lies  external  to  the  nj^mpha,  and  is  lost 


4  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGA>^S. 

anteriorly  on  the  corresponding  labium  majus.  It  is  not 
connected  with  the  clitoris  or  its  preiuice. 

The  labia  minora  are  very  sensitive,  and  are  among  the  last 
structures  to  yield  to  the  effects  of  ansesthetics.  They  are 
histologically  skin,  and  not  mucous  membrane  ;  their  deeper 
substance  is  erectile  tissue.  They  bleed  freely  when  wounded, 
but  the  haemorrhage  is  not  always  difficult  to  arrest. 

The  Clitoris. — In  the  anterior  angle  of  the  vulva  lies  the 
clitoris,  enveloped  in  its  prepuce.  "When  it  appears  enlarged, 
careful  examination  will  generally  show  that  in  reality  the  other 
parts  of  the  vulva  are  small  and  ill-developed.  This  condi- 
tion is  seen  in  sickly  young  adults  who  have  been  laid  up 
with  some  chronic  illness  during  puberty,  and  in  sterile  women 
with  small  uteri,  subject  to  dysmenorrhcea. 

The  Hymen. — This  is  a  cutaneous  fold,  most  developed 
posteriorly,  and,  as  a  rule,  more  or  less  crescentic  in  outline. 
It  is  separated  from  the  posterior  fourchette  by  the  fossa  navi- 
cularis,  although  this  depression  can  hardly  be  said  to  exist 
until  the  parts  are  artificially  separated.  The  hymen  may 
conveniently  be  described  as  the  end  of  the  vagina  and  the 
beginning  of  the  vulva,  the  foiu-chette  marking  the  outer  limits 
of  the  vulva,  although  this  point  is  disputed  by  some  authorities, 
who  speak  of  the  hymen  as  entirely  below  the  vagina. 

The  nature  and  varieties  of  the  hymen  are  matters  of  some 
importance  to  the  surgeon.  In  operations  about  the  vulva  and 
vagina,  and  in  any  examination  by  insjiection  or  digital  exjjlora- 
tion,  certain  peculiarities  in  this  structure  may  be  mistaken  for 
tumoirrs,  or  for  evidence  of  some  other  form  of  disease,  and  the 
patient  may,  in  consequence,  be  subjected  to  needless,  if  not 
absolutely  objectionable,  operative  or  therapeutic  measm-es.  I 
shall,  therefore,  proceed  to  describe  the  princijial  varieties  of 
liymen,  taking  for  my  guide,  where  personal  experience  may 
1)0  wanting,  R.  Dohrn's  valuable  monograph,  "  Die  Bildungs- 
feliler  des  Hymens"  {ZcitscJn-ift  fur  GchnrtshuJfe  und  Oi/iiuliologie, 
vol.  xi.,  1885). 

In  infancy  the  hymen  bears  the  appearance  of  a  pair  of  labia 
{lahi(form  hymen),  Fig.  3,  I.  Instead  of  forming  a  horizontal 
diaphragm,  it  is  folded  in  two  parts,  the  inner  surfaces  of 
which  lie  in  contact,  whilst  the  edges  of  the  aperture  point 


HYMEN. 


downwards.  As  the  external  labia  are  flattened  they  may  be 
overlooked  by  an  inexperienced  observer,  the  internal  labia 
being  taken  for  the  external,  whilst  the  hymen  is  mistaken  for 
the  internal  labia.  I  have  heard  it  suggested,  in  the  course  of 
an  examination  of  an  infant  with  vulvitis,  that  the  hymen,  in 
reality  unaffected,  was  "absent"  or  "  evidently  torn."  In  some 
infants  the  posterior  part  of  the  hymen  is  thick  and  fleshy, 
forming  a  prominence  closely  resembhng  a  small  polypus  (Jiynu'n 
linguUformis,  Fig.  3,  II.).  This  condition  always  disappears  as 
the  subject  grows  older. 


Fig.  3,  I. — Labieform  Hymen. 

( Tardieu. ) 


Fig.  3,  II. — Lingulate  Hymen. 
(Dohrn. ) 


In  childhood,  iis  the  neighbouring  parts  widen,  the  hymen 
becomes  more  and  more  horizontal  in  position,  the  opposite 
sides  gradually  unfolding.  Lastly,  later  on,  the  edges  of  the 
orifice  come  to  he  apart. 

In  the  adult  virgin  the  hymen  forms  a  ring,  generally  broadest 
posteriorly.  This,  the  commonest  type,  is  the  hymen  annularis. 
In  the  hymen  circularis  the  orifice  is  precisely  central,  the  anterior 
part  of  the  membrane  being  as  broad  as  the  posterior.  This  is 
not  a  rare  form  ;  it  may  puzzle  the  surgeon,  before  careful 
examination.  The  clitoris  and  meatus  lu-inarius  are  safe  land- 
marks for  the  explorer.  The  orifice  is  long  and  narrow,  and  the 
posterior  part  of  the  membrane  is  broad,  in  the  hy)nen  semihinariti; 
whilst  in  the  hymen  falciformis  the  orifice  is  long  and  somewhat 
wide,  the  membrane  being  narrow.  The  posterior  attachment 
of  the  hymen  is  on  a  lower  plane  than  the  anterior. 


6  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

Ahnonnalities  in  the  Free  Edge  of  the  Hymen  constitute  several 
distinct  varieties.  In  the  hymen  deniiculatus  the  edges  are,  in 
part,  thick  and  fleshy,  and  elsewhere  thin,  forming  irregular 
folds.  It  is  a  persistent  form  of  the  infantile  type.  It  is 
observed,  not  rarely,  in  elderly  sulDJects.  This  denticulate 
hymen  is  the  form  most  readily  Hable  to  be  mistaken  for  a 
ruptured  hymen,  where  the  edges,  after  a  few  weeks  of  cohabita- 
tion, tend  to  thicken.  In  the  denticulate  hpnen,  however,  the 
folds,  when  pressed  upon,  disappear,  as  they  involve  the  edge 
only  of  the  membrane.  In  the  ruptured  form  the  edge  of  one 
fold  at  least  may  be  traced  thi'ough  the  membrane,  often  as  deep 
as  its  \-idvar  attachment.  In  a  rare  form,  the  edge  of  the  hymen 
is  delicately  notched.  This  is  the  hymen  fmbriatus,  said  to 
represent  persistence,  not  of  the  infantile,  but  of  the  foetal 
condition.  I  believe  that  only  one  genuine  example  of  this 
type  has  been  discovered  (Luschka's  case) .  The  cases  described 
by  Winckel,  Hoffmann,  and  Gfuenier  were  simply  instances  of 
papilloma  of  the  -^Tilva  involving  the  edge  of  the  hymen. 

Abnormalities  in  the  Plane  of  the  Hymen. — In  the  hymen  infimdi- 
biilifornm  the  membrane  is  completely  everted.  Its  edge  looks 
not  only  downwards,  but  outwards,  the  inner  surface  of  the 
membrane  being  fully  displayed.  Thus,  the  line  of  attachment 
of  the  hymen  to  the  vagina,  at  iii'st  sight,  looks  like  the  free 
border  of  a  normal  hymen.  This  form  is  a  persistence  of  the 
infantile  tj'pe.  "S^Tien  very  exaggerated  it  is  termed  hymvn 
/lypertrophieus.  It  is  generally  associated  ^^ith  imperfect  de- 
velopment of  some  part  of  the  reproductive  organs. 

Alleged  "  Multiple  HymenJ^ — The  terms  "  hymen  duplex  "  or 
•'  Jiymen  multiplex  "  are  often,  I  believe,  of  questionable  accuracy, 
anatomically  speaking.  For  the  surgeon,  however,  the  fact  is 
of  some  importance,  that  folds  resembling  valvuloe  conniventes 
are  sometimes  develo])ed  in  the  vagina ;  they  may  be  mistaken 
by  the  obstetrician  for  cicatrices  from  injuries  during  labour. 
I  shall  presently  refer  to  certain  precautions  against  mistaking 
a  true  hymen  for  one  of  these  folds.  In  rare  cases  the  fold 
lies  immediately  above  the  hymen,  and  may  really  have  been 
derived  from  that  membrane  in  the  course  of  its  development. 
L)r.  Fristo,  of  Metz,  described  in  the  Gazette  des  Ilopitaux,  1861, 
No.  96,  a  case  where  labour  was  obstructed  in  a  single  woman, 


HYMEN. 


aged  twenty-two,  by  fom-  circular  vaginal  septa,  with  orifices 
barely  admitting  the  point  of  the  little  finger.  They  were  so 
tough  that  a  bistoury  was  required  for  their  division.  The 
cliild,  abeady  dead,  was  turned  and  delivered.  Dr.  Fristo  then 
found  out  that  a  surgeon  had  divided  the  hymen  (or  more 
probably  a  fifth  vaginal  septum)  for  retained  menstruation  at 
puberty.  The  catamenia  afterwards  flowed  regularly  without 
obstruction,  but  complete  coitus  was  found  to  be  impossible. 
The  same  sm-geon  examined  the  patient  again,  and  informed 
her  that  the  vagina  was  incurably  obstructed.  She  relied  upon 
this  malformation,  and  was  greatly  surprised  when  she  became 
pregnant.  Here  I  may  observe  that  impregnation  has  repeatedly 
been  known  to  occur  whenever  the  normal  hymen  is  even  to  the 
least  extent  perforate. 


Fig.  4. — Hymen  Biseptus. 

(Museum  E.C.S.,  Fhysiological  Series,  'No.  2,841.) 


Ahnormalities  in  the  Cliamcter  of  the  Orifice  of  tlie  Hijmen. — In 
the  hymen  septus  or  hisejitus  there  are  two  orifices  divided  by  a 
thin  strip  of  membrane,  generally  broadest  posteriorly.     This 


S  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

strip  is  said  to  be  prolonged  from  tlie  middle  part  of  the  pos- 
terior column  of  the  vagina.  The  orifices  are  beheved  to 
represent  the  terminations  of  the  ducts  of  Miiller,  whence  the 
Fallopian  tubes,  uterus,  and,  at  least,  part  of  the  vagina  are 
developed ;  just  as  the  more  constant  Skene's  tubes,  in  the 
urethra,  appear  to  represent  the  ends  of  Grartner's  ducts.  On 
the  other  hand,  Breisky  has  observed  a  trace  of  the  original 
septimi  between  Miiller's  ducts,  in  the  vagina,  cjuite  distinct 
from  the  hymen. 

Sometimes  there  are  two  irregularly-placed  orifices  in  the 
hymen  (Jtymen  bifcncsfrafus  of  some  authors) ;  whilst  in  others 
three,  four,  or  even  as  many  as  eleven  apertui-es  have  been 
observed  (Jiymen  cvibriformis). 

Absence  of  ilie  Hymen. — I  shall  presently  refer  to  precautions 
against  overlooking  a  lax  hymen  with  its  upper  surface  com- 
pressed against  the  vaginal  wall.  Tardieu  and  DevilKers  failed 
to  detect  a  single  case  of  congenital  absence  of  the  hymen  after 
systematic  examination  of  a  large  number  of  infants,  but  several 
writers  declare  that  they  have  discovered  examples  of  this 
condition. 

Abnormal  PoHifion  of  the  Hymen. — The  hymen  sometimes 
appears  to  be  abnormally  high  in  the  vagina.  This,  however, 
is  generally  due  to  great  depth  or  peculiar  development  of  the 
vulva,  as  in  negresses.  The  alleged  cases  of  abnormally  low 
position,  where  the  hjTnen  has  been  reported  as  covering  the 
urethi'a,  are  simply  examples  of  abnormal  coalescence  of  the 
labia. 

Persistence  of  the  Hymen  during  Pregnancy. — This  has  been 
repeatedly  observed,  even  when  the  orifice  of  the  hymen  is 
narrow.  As  has  been  abeady  noted,  impregnation  after 
imperfect  coitus  is  not  rare.  The  orifice  ^v^.ll  even  allow  a 
sixth  months'  child  to  be  born  without  rupture,  as  in  Tolberg's 
case. 

Laceration  of  the  Hymen. — Schroder  has  shown  that  in 
laceration  of  the  hymen  from  coitus  only  the  free  border  of 
the  membrane  is  torn,  the  rent  seldom  extending  down  to  the 
line  of  attachment  to  the  vagina.  The  latter  condition  occurs 
at  the  first  labour  at  term,  and  it  is  on  that  occasion,  also, 
that  the  caruneulai  myrtiformes  are  first  developed.     A  history 


HYMEN,  9 

of  laceration  of  the  hymen  from  a  fall  or  from  a  blow  must 
always  be  received  with  extreme  caution.  Most  authorities 
admit  that  the  membrane  can  only  be  torn  by  a  force  exerted 
directly  against  it,  or  by  the  continuation  into  its  substance  of 
a  laceration  of  neighbouring  structures.  The  common  annular 
hymen  is  generally  torn  in  four  places,  whilst  a  semilunar  or  a 
very  tense  hymen  of  any  form  tears  at  one  point  along  the 
median  line  of  its  posterior  portion. 

The  Hymen  in  Atresia  Vnr/ime. — Dr.  Matthews  Duncan,  w^ho 
has  had  the  advantage  of  a  wide  experience  in  such  cases,  has 
repeatedly  found  a  perfect  hymen  associated  with  atresia  of  the 
vagina.*  In  one  case  the  vagina  was  opened  up  by  a  thermo- 
cautery knife,  and  retained  menses  let  out.  After  recovery, 
the  true  hymen  was  seen  to  be  perfectly  distinct  from  the 
vaginal  septum  which  had  been  cut  through.  Dr.  Duncan 
believes  that  the  blue,  thin-walled  structure  detected  between 
the  labia  is  generally,  but  often  erroneously,  called  imperforate 
hymen,  whereas  in  many  cases,  and  often  where  there  is  even 
total  absence  of  the  vagina  and  uterus,  a  hymen  can  be  dis- 
tinctly seen. 

General  Considerations  on  the  Hymen. — Some  of  the  forms  of 
hymen  above  described  are  not  always  easy  to  detect,  either  by 
sight  or  digital  exploration.  When  lax  the  hymen  may  lie 
against  the  vaginal  walls  with  its  free  border  upwards,  so  as 
to  escape  a  superficial  examination.  The  exploring  finger  will 
then  detect  a  constriction  higher  up  the  genital  canal  than  the 
level  of  the  hymen,  so  that  a  contraction  of  the  vagina  may 
be  suspected.  In  the  case  of  a  cribriform  hymen  this  error 
is  very  frequent.  Sometimes  the  finger  pulls  clown  the  hymen 
as  it  is  withdrawn,  then,  on  inspection,  that  structm'e  will  be 
discovered.  The  free  margin  of  the  hymen  lies  naturally  on 
a  higher  plane  than  that  of  its  posterior  attachments. 

Carunculse  Myrtiformes. — These  structures  are  correctly 
described  in  most  text-books,  for  it  is  the  subjects  that  possess 
them  who  are  the  most  frequently  examined  by  medical 
attendants.  In  women  who  have  had  very  few  children  they 
form  a  more  or  less  complete  circle  of  thin,  flaccid  folds ;  in 

*  "Case  of  so-called  Imperforate  Hymen"  {Trans.  Ohdet.  Soc,  vol.  xxiv., 
1882). 


10 


THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 


multipara?  they  are  often  reduced  to  two  or  three  prominent 
flesh}'  wattles.  In  nullipara3  who  are  not  virgins  the  h^nnen  is 
generally  reduced   to  two  unsymmetrical  portions  divided  by 


Fkj.  5. — Vulva  of  an  Adult  laid  oim;x   by  Divlsiox   of  the   Fo.steiiiou 

comjilssuke. 
The  vestibule  is  well  displayed,  but  its  posterior  margin  has  become  irregular 
tlirough'the  action  of  s^nrit.  The  orifices  of  the  vestibular  follicles  appear 
above  and  below  the  meatus  urinarius.  A  bristle  lies  in  each  orifice  of  Cowper's 
ducts.  The  relations  of  the  labia  minora  to  the  clitoris  are  well  shown.  Poste- 
riorly the  normal  relations  have  been  completely  eliaced.  {Museum  R.C.S., 
Physiological  Series,  No.  2,830.) 

the  laceration,  the  edges  of  which,  as  well  as  the  free  border  of 
the  hymen  itself,  are  always  more  or  less  thickened,  but  the 
two  portions  can  hardly   be  called   caruncles.     The   orifice  of 


VESTIBULE.  11 

Cowpei^'s  duct  may  often  be  detected  immediately  outside  a 
large  caruncle  a  little  posterior  to  the  mid-line  between  the 
clitoris  and  the  posterior  limits  of  the  vulvar  aperture.  Most 
writers  seem  to  consider  that  it  Kes  much  farther  back. 

When  the  hymen  has  been  torn  and  the  carunculEC  have 
formed,  the  vaginal  outlet  at  the  most  posterior  point  of 
attachment  of  the  hymen  has  almost  invariably  shared  in  the 
laceration,  so  that  the  tissues  of  the  fossa  navi'cularis  become 
more  or  less  involved  towards  or  as  far  as  the  posterior  four- 
■chette.  These  lacerations  totally  alter  the  appearance  of  the 
vulva  as  seen  in  virginity,  the  alteration  likewise  involving 
atrophy  of  the  prominent  posterior  extremities  of  the  labia 
majora.  Hence  the  structures  at  the  posterior  extremity  of 
the  vulva  become  hard  to  distinguish.  When  the  fourchette 
itself  is  torn,  the  perineum  is,  by  definition,  involved  in  the 
laceration,  since  the  fourchette  is  its  anterior  extremity, 

.  Vestibule. — Below  the  clitoris  is  a  smooth,  triangular 
surface,  with  its  plane  almost  level  with  the  horizon  (Fig.  5). 
It  is  prolonged  to  each  side  of  the  vulva,  as  the  woodcut  shows. 
This  is  the  vestibule,  and  neither  the  anterior  nor  the  posterior 
vaginal  walls  should  be  visible  behind  it,  excepting  in  multiparse, 
where  a  trifling  amount  of  descent  appears  to  be  natural.  The 
vestibule  is  much  wider  in  some  subjects  than  in  others. 
Conspicuous  on  the  surface  of  the  vestibule  is  the  meatus 
urinarius.  Thanks  to  the  characteristic  smooth  surface  of  the 
vestibule,  well  supported  by  the  triangular  ligament,  the  orifice 
of  the  meatus  is  not  hard  to  detect  for  purposes  of  catheterism. 
Here  too  I  may  observe  that  the  vestibule  is  not  stretched  in  the 
second  stage  of  labour ;  though,  according  to  Matthews  Duncan , 
its  mucous  membrane  may  be  pushed  forwards  and  torn  longi- 
tudinally. Two  clusters  of  large  mucous  follicles  open  by  ducts 
on  the  surface  of  the  vestibule;  one  group  lies  immediately 
behind  the  clitoris,*  the  other  behind  and  at  the  sides  of  the 
meatus.  Similar  groups  are  found  on  the  inner  aspect  of  the 
nymphge,  and  in  the  fossa  navicularis.  These  follicles  secrete 
mucus  very  freely,  when  any  som^ce  of  persistent  local  irritation 
exists.  Their  arrangement  is  well  figui-ed  in  Dr.  Henry  Savage's 
atlas. 

*  Hence  the  origin  of  the  small  cyst  occasionally  found  in  this  situation. 


12  THE    SIRGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

The  meatus  uriuarius  varies  considerably  in  appearance  in 
healthy  subjects.  The  urethral  mucous  membrane  often  bulges 
from  its  ring-like  margin.  Most  remarkable  is  the  presence  of 
caruncles,  sometimes  of  considerable  size,  and  intensely  red,  in 
cases  where  they  cause  no  pain  dui-ing  mictimtion,  nor  any 
other  subjective  symptom.  On  each  side  of  the  elevated  margin 
of  the  meatus,  somewhat  posteriorly,  is  a  minute  pore.  I  cannot 
admit  that  it  is  easy  to  detect  in  healthy  subjects,  for  I  have 
searched  for  it  in  hundreds  of  patients.  In  chronic  gonorrhoea, 
or  leueorrhcea,  the  pair  of  pores  are  often  discovered  without 
difficulty.  They  are  the  orifices  of  Skene's  tubes.  The  sm-geon 
must  remember  that  they  are  certainly  gland-ducts,  liable  to 
morbid  changes,  especially  in  chronic  gonorrhoea.  Their  precise 
significance  is  a  piu-ely  scientific  cj^uestion. 

Orifice  of  Cowper's  Ducts. — On  everting  one  of  the  labia 
minora,  and  pressing  the  hj'men  inwards,  a  small  red  depression 
may  generally  be  seen  on  the  vulva,  somewhat  posteriorly. 
This  dej^ression,  seldom  very  distinct,  leads  to  the  orifice  of 
Cowper's  duct.  It  is  most  conspicuous  when  the  hjTnen  is 
replaced  by  earunculte.  I  must  here  remark,  that  in  searching- 
for  this  duct,  for  Skene's  tubes,  or  for  similar  struetiu"es  in  the 
live  subject,  mthout  auEesthetics,  it  is  not  advisable  to  try  to 
l^ass  a  bristle  or  a  fine  probe.  Such  an  attempt  is  certain  to 
produce  great  iiTitation. 

Cowper's  gland  itself  is  a  simple  collection  of  tubules,  form- 
ing an  oval  body  about  half  an  inch  in  its  long  diameter  ;  it 
lies  against  the  posterior  part  of  the  vaginal  orifice,  under  the 
superficial  perineal  fascia,  and  covered  by  the  fibres  of  the 
sphincter  vaginae.  After  the  twenty-fifth  year  it  becomes 
smaller,  and  ultimately  atroj)hies.  In  emaciated  subjects,  such 
as  are  seen  in  dissecting  rooms,  this  gland  is  extremely  difiicult 
to  find.  Abscess  of  this  gland  and  cystic  dilatation  of  its  duct 
are  two  well-known  diseases.  Suppuration  of  the  duct,  and 
cystic  degeneration  of  the  gland  are,  on  the  other  hand,  rare. 

The  Vagina. — Many  erroneous  notions  are  prevalent  about 
the  anatomy  of  the  vagina.  It  is  often  represented  as  a  con- 
stantly open  tube,  bent  upon  itself  at  a  somewhat  indefinite 
angle,  apparently  so  as  to  fit  into  the  concavity  of  the  sacrum, 
which,  in  reality,  lies  far  above  and  behind  it.     I  have  heard 


VAGINA.  Vi 

surgeons  and  obstetricians  ask  how  a  "  tube  like  the  vagina  " 
could  have  an  anterior  and  posterior  wall  ?  Grreat  errors  appear 
likewise  to  prevail  on  the  subject  of  the  length  of  the  vagina. 

The  vagina  is  a  structure  with  distinct  coats,  but  it  chiefly 
consists  of  a  wide  mucous  siu'face,  which  is  lax,  so  that  a  canal 
can  be  formed  for  the  passage  of  the  intromittent  organ,  the 
foetus,  surgical  instruments,  or  fluids  passing  outwards  or 
inwards.  In  fact,  the  vaginal  canal  is  only  "potential."* 
It  never  forms  a  cavity  in  any  natural  position  of  the  body. 
I  shall  return  to  this  subject  when  speaking  of  the  genu- 
pectoral  and  semi-prone  positions  in  the  examination  of 
patients. 

The  mucous  surface  of  the  vagina  is  folded  on  itself,  with 
a  slight  puckering  at  each  side,  so  that  a  true  anterior  and 
posterior  wall  are  formed.  The  anterior  wall  is  broad  above, 
where  it  is  reflected  on  to  the  anterior  lip  of  the  cervix  uteri, 
forming  a  slight  depression — the  anterior  fornix-  Below,  this 
wall  ends  at  the  hymen,  here  it  is  very  narrow.  The  mucous 
membrane  of  this  wall  forms  transverse  rugse,  well  marked  in 
virgins,  but  almost  effaced  in  multiparse.  A  vertical  fold, 
bounded  by  thickened  mucous  membrane,  and  nearly  an  inch 
long,  lies  close  above  the  urinary  meatus.  This  fold  is  termed 
the  anterior  column  of  the  vagina.  When  very  well  marked,  it 
may  be  taken  for  a  morbid  condition.  The  urethra  is  in 
intimate  relation  with  the  lower  part  of  the  anterior  vaginal 
wall.  The  bladder  is  separated  from  that  wall,  higher  up, 
by  connective  tissue,  which  probably  becomes  more  abundant 
during  pregnancy. 

In  many  women,  especially  in  multiparge  over  thirty  years 
of  age,  the  lower  part  of  this  wall  descends  considerably 
towards  the  vulva,  without  necessarily  causing  inconvenience. 
When  this  condition  increases,  however,  the  bladder  always 
follows  the  vaginal  wall  in  its  descent,  as  the  catheter  ^^^ll 
prove.  At  first,  the  base  only  descends,  and  then  the  catheter 
can  be  passed  through  the  meatus  either  downwards,  so 
that  it  can  be  felt   through   the   prolapsed   vaginal   wall,    or 

*  "  The  vault  of  the  vagina  "  is  also  a  mere  expression,  though  very  convenient. 
The  reflection  of  the  vagina  on  to  the  cervix  is  in  no  way  a  "  vault  "  in  a  uieclian- 
ical  or  architectural  sense. 


14 


THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 


upwards  into  the  undescended  part  of  the  bladder.  ^Yhen 
the  descent  of  the  wall  is  extreme,  the  greater  part  of  the 
vesical  cavity  lies  in  the  pouch  formed  by  the  prolapsed  wall. 

The  anterior  vaginal  wall,  fi-om  the  hymen  to  the  anterior 
vaginal  fornix,  measures,  on  an  average,  a  little  over  two 
inches.     Its  course  is  almost  in  a  straight  line. 

The  posterior  vaginal  wall  is  also  triangidar,  and  its  base 
likewise  lies  above.     It  measm-es,  on  an  average,  three  inches. 


Fk;.  C. — YEirricAL  Section'  of  the  Pelvic  Viscku.v  of  ax  Adult  Yiiioix. 

Showing  tlie  outline  of  the  anterior  and  posterior  vaginal  walls,  the  position 
of  the  uterus,  and  the  shape  of  tlie  bladder  when  nearly  empty.     (After  Foster.) 

It  commences  at  the  vulva,  and  ends  above  b}'  a  reflection  on 
to  the  back  of  the  cer\ix  uteri,  forming  here  a  deep  and  very 
distinct  pouch — the  jwsten'or  fornix,  or  ciil-de-mc.  Its  mucous 
lining  bears  transverse  ruga3  and,  below,  an  ill-marked  pos- 
terior column.  Successively^  from  below  upwards,  the  perineal 
body,  rectimi,  and  the  peritoneal  fold  known  as  Douglas's 
pouch,  lie  behind  it.  This  wall  is  separated  from  tlie  rectum 
superiorly  by  much  loose  connective  tissue,  which  is  continu- 
ous on   each  side    of  the   vagina,  Avith  the  connective   tissue 


VAGINA.  15 

between  the  vagina  and  bladder.  This  tissue  apj)ears  to 
increase  diu'ing  pregnancy,  and  sometimes  becomes  subject  to 
a  kind  of  subinvolution.  However  this  abnormal  looseness  of 
the  tissue  may  be  produced,  it  certainly  sometimes  exists,  and 
plays  an  important  share  in  the  mechanism  of  prolapse  of  the 
uterus,  vagina,  or  bladder. 

The  posterior  vaginal  wall  makes  a  sigmoid  curve,  which 
varies  according  to  the  condition  of  neighbouring  organs. 

Hart  and  Barboui^,  and  many  other  living  authorities,  main- 
tain that  the  vaginal  walls  lie  in  apposition,  excepting  around 
the  vaginal  part  of  the  cervix,  in  any  natural  position  which 
the  patient  may  assume. 

The  vagina  being  natm-ally  closed,  it  is  evident  that  any 
instrimient  or  appliance  which  keeps  its  walls  apart  must  be, 
so  far,  unnatural.  Diseased  mucous  sm-faces,  however,  are  best 
kept  apart,  and  certain  mechanical  supports  have  proved  to  be 
of,  at  least,  empirical  value,  in  some  cases,  possibly,  on  this 
principle  alone. 

When  the  subject  stands  straight  up,  the  long  axis  of  the 
vagina  makes  an  angle  of  about  60'^  with  the  horizon,  so  that, 
as  Hart  and  others  have  noted,  it  is  almost  parallel  to  the  pehdc 
brim. 

The  surgeon  can  understand  from  the  above  description  that 
the  long  axis  of  the  vagina  above  is  at  right  angles  to  that  of 
the  vulva  below,  the  former  being  transverse,  the  latter  running 
from  before  backwards.  This  fact  must  especially  be  remem- 
bered during  the  introduction  of  a  pessary. 

One  of  the  most  important  structm-es  to  be  found  on  the 
outer  side  of  the  vagina  is  the  anterior  part  of  the  levator 
ani  muscle.  When  in  a  state  of  contraction,  the  pair  of  levatores 
compress  the  vagina  considerably. 

The  mucous  membrane  of  the  vagina,  is  lined  with  stratified 
epithelium,  squamous  superficially.  It  ajopears  to  possess 
glandular  structures,  but  not  in  abundance,  and  their  j^reeise 
uatiu'e  and  structui'e  are  disputed. 

The  vagina  possesses  a  distinct  muscular  coat,  composed  of 
plain  muscular  fibres.  Strange  to  say,  their  direction  is  dif- 
ferently described  by  different  authorities ;  at  least,  there  is  a 
layer  of  longitudinal  and  a  layer  of  circular  fibres,  but  autho- 


16  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

rities  are  divided  as  to  which  of  the  two  is  external.  The 
sphincter  vaginas  surrounds  the  lower  portion  of  the  vagina ;  it 
is  a  weak  muscle,  the  levator  ani  being  the  true  constrictor  of 
the  vao-ina.  External  to  the  muscular  coat  is  the  connective 
tissue  already  described,  and  a  rich  plexus  of  veins. 

The  Uterus. — The  general  aspect  of  this  organ  must  be 
familiar  to  every  anatomist  and  surgeon.  The  relations  and 
minute  anatomy  of  the  uterus,  the  nature  of  its  walls,  its 
mucous  membrane,  and  its  supports  have  been  studied  and 
discussed  for  three  centm-ies  at  least  by  anatomists,  physio- 
logists, and  obstetricians.  Notwithstanding  this  fact,  tliere  is 
hardly  one  single  point  respecting  its  structure  and  relations 
that  remains  undisputed. 

The  lower  part  of  the  cervix  with  the  os  externum  lie  in 
the  vagina,  accessible  to  the  finger  and  visible  to  the  eye, 
aided  by  mechanical  contrivances.  The  fundus  and  body  are 
exposed  in  abdominal  section.  The  appearance  of  the  body 
of  the  uterus,  when  no  abnormality  or  no  alteration  due  to 
adhesions  exists,  is  very  characteristic.  Hence  there  is  no 
better  landmark  for  the  operator.  When  he  can  see  or  touch 
the  uterus,  he  knows  where  the  bladder  should  be.  By  guid- 
ing a  finger  or  sponge  down  the  back  of  the  uterus,  he  will 
find  the  way  to  Douglas's  pouch,  or,  at  least,  can  discover 
anything  which  may  occupy  that  fold  of  the  peritoneum. 
Most  important  of  all  are  its  lateral  relations  to  the  tubes 
and  ovaries.  These  structm-es  are  rapidly  altered  by  disease. 
By  searching  along  the  fundus  and  the  uterine  end  of  the 
tube,  which  is  rarely  hard  to  find  or  recognize,  however  much 
the  remainder  of  the  tube  may  be  altered  or  concealed,  the 
siu-geon  can  at  least  discover  where  the  appendages  lie  and 
how  far  they  are  movable  or  fixed  by  adhesions,  even  though 
he  may  fail  to  detect  their  component  parts.  The  pregnant 
uterus  is  a  very  conspicuous  object,  rising  above  the  pubes, 
soft  and  vascular.  Its  appendages,  turgid  with  blood,  run 
downwards  from  its  sides. 

Wlien  the  uterus  is  malformed  or  concealed  by  intimate  adhe- 
sions to  a  tumom-  or  to  a  normal  structm-e,  the  best  landmark  is 
lost,  and  the  surgeon  will  have  to  rely  on  far  less  certain  guides. 
In  such  cases,  the  bladder  especially  will  have  to  be  sought 


UTERUS.  l7 

with  care,  and  with  the  aid  of  the  catheter ;  and  the  dilficuhy 
of  distinguishing  collapsed  intestine  from  diseased  appendages 
must  be  home  in  mind.  In  the  case  of  a  tumour  strongly 
adherent  to  the  pelvic  viscera,  the  walls  of  its  pelvic  portion 
are  often,  unfortunately,  so  thick  that  the  outhne  of  the  body 
of  the  uterus  cannot  be  felt  through  them. 

Uterine  tissue  bleeds  very  freely  when  wounded,  whether  by 
incision  or  by  the  tearing  off  of  its  serous  coat  in  detaching 
adhesions.  Of  all  structures  in  the  body,  it  is,  I  believe,  the 
most  untru-stworth}^  for  treatment  by  ligature  and  for  the 
application  of  sutures.  The  muscular  walls  of  the  uterus 
undergo  certain  contractions  and  relaxations  in  relation,  it 
would  appear,  to  menstruation  as  well  as  to  pregnancy  and 
parturition.*  These  changes,  or  rather  movements,  must  be, 
to  a  great  extent  tidal,  regular,  and  hence  possibly  calculable ; 
still  the  amount  of  j)i"ecise  knowledge  on  the  subject  remains 
limited.  As  to  the  effects  of  disease  and  injury  on  the  uterine 
muscular  tissue,  we  are  aware  that  there  are  such  effects,  but 
we  know  nothing  precise  and  rehable  about  them.  A  stout 
ligature,  tied  tightly  round  the  stump  of  a  fibroid,  may  become 
perfectly  loose  in  a  few  minutes.  I  am  now  speaking  in 
general  terms ;  in  the  chapters  on  Uterine  Surgery  I  shall 
discuss  the  subject  of  ligature  at  greater  length.  At  present  it 
may  be  understood  that  the  clamp,  which  can  be  tightened  at 
will,  is  more  reliable  for  the  secm-ing  of  uterine  tissue  than  the 
ligature,  which  does  not  allow  of  similar  control. 

D'unensions  and  Weight. — In  a  well-formed  adult,  the  unim- 
pregnated  uterus  measures,  on  an  average,  about  three  inches 
in  length,  two-and-a-quarter  in  breadth  at  the  fundus,  and  not 
quite  an  inch  in  thickness.  The  uterine  cavity  and  the  cervical 
canal  together  measure  about  two-and-a-half  inches.  The 
uterus  weighs  about  one  ounce,  but  in  nearly  all  morbid  condi- 
tions its  weight  is  increased. 

Communication  hetween  the  Peritoneal  Camty  and  the  Genital 
Tract. — In  respect  to  the  cavity  of  the  uterus,  the  sui'geon 
must  not  forget  that  it   bears   an   absorbent  mucous  sm'face,. 

*  See  Matthews  Duncan  "On  Contraction,  Inhibition,  and  Expansion  of  the 
Uterus,"  and  "On  Elasticity,  Retraction,  and  Polarity  of  the  Uterus"  {Trans- 
actions oftlic  Obstetrical  Society  of  London,  vol.  xxviii.,  1886). 

C 


18  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

and  that  it  communicates  with  the  vagina  on  the  one  hand, 
and  with  the  peritoneal  cavity  through  the  tubes  on  the  other. 
Hence  there  is  a  highway  into  the  peritoneum  from  the  ex- 
terior of  the  body.  The  danger  of  neglecting  vaginal  dis- 
charges, and  of  introducing  dii'ty  sounds,  or  of  wounding  the 
uterine  mucous  membrane  with  stems,  sounds,  or  cutting  in- 
struments can  thus  be  readily  understood.  Fortunately,  the 
irritation  set  up  by  septic  material  generally  produces  inflam- 
matory changes,  which  cause  the  fimbriated  extremities  of  the 
tube  to  become  closed.  This  condition  saves  the  peritoneum 
from  sources  of  irritation  which  otherwise  would  be  more  fre- 
quent. Closure  of  the  tubes,  however,  is  in  itself  a  cause  of 
suifering  and  risk. 

Body  of  the  Utenis. — The  body  of  the  uterus  is  triangular, 
with  its  base  or  fundus  markedly  convex;  the  sides  are  also 
convex.  The  anterior  surface  is  flat,  the  posterior  is  somewhat 
convex,  especially  in  its  upper  third  ;  this  is  often  well  marked 
when  the  uterus  is  hypeiirophied  from  various  causes. 

In  sterile  subjects  with  ill-developed  uteri,  the  body  is  flat 
on  both  sides  and  short,  and  the  fundus  looks  unusually  broad. 
The  cervix,  on  accoimt  of  the  arrested  development  of  the  body, 
appears  very  long,  as  in  infancy. 

From  each  extremity  of  the  fundus  arise  the  Fallopian  tubes, 
presently  to  be  described.  The  peritoneum  reflected  over  the 
uterus  is  also  reflected  over  the  tubes  and  the  parovarium, 
forming  the  broad  Ufjnmcrd.  Close  below  and  posterior  to  the 
uterine  extremity  of  each  tube,  a  short  cord-like  prolongation 
of  uterine  muscular  tissue  springs  from  the  body  of  the  uterus. 
This  is  the  ovarian  ligament,  and  it  is  conspicuous  from  behind, 
as  it  hes  in  a  shallow  peritoneal  fold. 

Round  Ligament. — From  each  side  of  the  uterus,  in  front, 
springs  the  round  ligament.  It  runs  upwards,  outwards,  and 
forwards,  enters  the  inguinal  canal,  and  ends  partly  in  the  con- 
nective tissue  of  the  mons  Veneris,  but  its  fibres  have  a  compK- 
cated  relation  anteriorly  to  the  aponeurotic  and  tendinous 
structures  which  surround  it — a  relation  differently  described 
by  different  anatomists.  It  chiefly  consists  of  unstriped 
muscular  fibres ;  in  fact,  it  is  a  prolongation  of  the  muscular 
wall   of   the   uterus.      In   its   more   anterior  portion,    striped 


UTERUS.  19 

fibres  are  found.  The  round  ligament  receives  a  branch,  from 
the  ovarian  artery,  and  bears  lymphatic  vessels  which  maintain 
a  free  communication  between  the  lymphatics  of  the  uterus  and 
the  inguinal  glands.  In  the  inguinal  canal,  it  has  the  same 
relations  as  the  spermatic  cord  in  the  male.  The  round  liga- 
ment is  the  part  essentially  concerned  in  Alexander's  operation. 
Peritoneal  Fossce  around  the  Uterus. — Besides  the  broad  liga- 
ment, there  is  another  reflection  of  the  peritoneum,  on  to  the 
bladder ;  this  forms  the  utero-vesical  ligament.  Posteriorly  there 
is  yet  another  reflection  from  each  side  of  the  body  of  the  uterus 
reaching  the  second  sacral  vertebra.  The  pair  form  two  sharp 
folds,  which  contain  unstripecl  muscular  fibre  prolonged  from 
the  uterine  walls,  but  not  so  much  of  that  tissue  as  is  found 
in  the  round  ligaments.  These  are  the  utero-mcral  ligaments. 
Between  them  lies  Douglas's  -pouch,  which  dips  deeply  between 
the  uterus  and  rectum,  extending  as  far  as  the  posterior  fornix 
of  the  vagina.  The  sharp  edges  of  the  utero-sacral  folds  are 
readily  detected  on  rectal  examination. 

Cavity  of  the  Uterus. — The  body  of  the  uterus  contains  a 
triangular  cavity  with  the  base  towards  the  fundus,  and  the  apex 
below,  where  the  cavity  becomes  continuous  with  the  canal  of 
the  cervix  at  the  os  internum.  It  has  an  anterior  and  a  posterior 
wall ;  its  sides  are  convex.  A  Fallopian  tube  opens  into  each 
of  the  upper  angles. 

Uterine  Mucous  Membrane  :  Endometrium. — The  cavity  is  lined 
with  a  mucous  membrane  bearing  ciliated  epithelium  and  special 
glands ;  it  appears  to  be  very  thin,  unless  the  theory  be  true 
that  a  part  of  the  muscular  wall  beneath  it  must  be  considered 
as  partly  mucous  and  submucous  tissue.  This  membrane  (the 
endometrium)  undergoes  special  changes  in  pregnancy,  forming 
the  uterine  decidua.  A  question  of  more  importance,  perhaps, 
to  operators,  but  still  very  imsettled,  is  the  precise  nature  of  the 
changes,  if  any,  which  the  mucous  membrane  undergoes  in 
relation  to  menstruation.  The  researches  of  Drs.  Jacoby  and 
Arthur  Johnstone  and  Mr.  Sutton  may  throw  light  on  this 
question,  and  on  the  disputed  nature  of  the  form  of  uterine 
disease  known  as  endometritis.  At  present  nothing  more  can 
be  said,  except  that  the  uterine  mucous  membrane  is  easily 
damaged  by  instruments.     Such  injury  may  set  up  peritonitis. 


20  THE    SIRGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

in  the  manner  indicated  at  page  18,  or  may  cause  inflammatory 
chano'es  to  extend  to  the  connective  tissue  outside  the  uterus,  so 
as  to  develop  pelvic  cellulitis. 

Muscular  WaJh  of  the  Uterus. — The  body  of  the  uterus 
consists  of  a  thick  muscular  wall  lined  with  the  mucous 
membrane  just  described,  and  covered  with  peritoneum,  forming 
its  serous  coat. 

The  muscular  ^ya]l  is  chiefly  made  up  of  plain  muscular 
fibres  aiTanged,  it  is  generally  admitted,  in  three  layers.  The 
middle  layer  contains  numerous  venous  sinuses.  The  minute 
anatomy  of  the  muscular  wall  of  the  uterus,  and  the  changes 
which  it  rmdergoes  dm^ing  pregnancy,  are  not  pertinent  to  the 
subject  of  this  work.  The  muscular  wall  is  tough,  but  easil}^ 
woimded ;  it  is  then  hable  to  bleed  fi*eely. 

The  serous  or  peritoneal  coat  of  the  uterus  closely  invests 
the  entire  fundus  and  body  before  and  behind,  and  reaches 
as  low  as  the  supra-vaginal  part  of  the  cervix  posteriorly.*  It  is 
continuous  in  front  vdih  the  utero-vesical  fold,  behind  with  the 
anterior  part  of  the  fold  which  forms  Douglas's  pouch,  and 
laterally  with  the  broad  ligaments,  but  more  will  be  said  on 
these  relations  presently.  The  peritoneum  is  not  difficult  to 
strip  off  from  the  muscular  wall ;  in  some  operations  this 
process  has  been  done  pm'posely. 

The  vascular  supply  of  the  uterus  will  presently  be  described. 
The  Cervix  Uteri. — This  structm-e  is  a  very  distinct 
segment  of  the  uterus,  and  many  authorities  teach  that  it  is 
practically  a  different  organ  from  the  body.  A  large  portion  of 
the  cervix  lies  in  the  upper  part  of  the  vagina,  where  it  is  ac- 
cessible to  the  finger,  and  can  be  seen  by  the  aid  of  several 
methods  which  the  sui'geon  must  learn  to  practise  skilfidly.  In 
pregnancy  it  becomes  very  soft,  and  is  graduall}'  di'awTi  up,  till 
it  is  lost  in  the  body  of  the  uterus.  It  is  particularly  impor- 
tant that  the  sm-geon  should  learn  to  recognise  the  feeling  of 
tlie  cer-\dx  diu-iug  pregnancy.  If  he  attempt  to  practise  what  is 
understood  as  pure  gynaecology  without  some  pre-sdous  knowledge 

*  Discrepancies  as  to  the  precise  position  of  the  os  internum  account  for  the 
ilitt'crence  in  descnptions  of  the  relation  of  the  peritoneum  to  the  lower  portion  of 
tlip  front  of  the  body  of  the  uterus.  "Whether  the  peritoneum  here  dips  down  as 
far  as  the  .sui)ra-vaginal  part  of  the  cervix  is  a  matter  of  little  real  importance. 


CERVIX    UTERI.  21 

of  obstetrics,  lie  will  assiu-edly  fall  into  grievous  errors.  The 
cervix  is  very  insensitive.  Some  patients  can  even  bear  the 
application  of  the  cautery  to  its  tissues,  and  few  complain  of 
pain  when  it  is  grasped  by  the  volsella.  Many  practitioners 
speak  in  clinical  reports  of  a  cervix  being  "  exquisitely 
tender."  In  an  overwhelming  majority  of  such  cases  the  pain 
is  due  to  some  other  part  being  moved  when  the  cervix  is 
touched.  In  digital  exploration,  many  practitioners  hook  the 
cervix  forcibly  back  with  the  fore-finger.  This  moves  the 
whole  uterus,  and  causes  pain  even  in  health. 

The  cervix  lies  partly  above  the  vagina.  The  portion  in  this 
position  is  therefore  called  supra- vaginal ;  it  is  invested  by 
peritoneum  behind,  and  by  loose  cellular  tissue,  which  connects 
it  to  the  bladder  in  front.  The  broad  ligaments  lie  on  each 
side.  These  relations  are  important  to  remember  in  the  coiu'se 
of  any  operation  on  the  uterus  or  cervix.  The  body  of  the 
uterus  is  naturally  bent  forwards  on  this  part  of  the  cervix. 
The  back  of  the  supra-vaginal  ]3ortion  of  the  cervix  is  easily 
felt  through  the  walls  of  the  rectum.  It  feels  very  resistant, 
and  must  not  be  taken  for  a  fibroid  growth  in  the  posterior 
wall  of  the  uterus. 

The  infra-vaginal  portion  of  the  cervix  (portio  vaginalis,  pars 
vaginalis)  projects  into  the  vagina.  In  virgins  it  forms  a 
small  cone,  pointing  somewhat  forwards  and  feeling  flattened 
anteriorly,  and  the  os  externum  is  a  small  circular  dej)ression. 
These  peculiarities  are  retained  more  or  less  in  all  nulliparous 
women  who  are  not  virgins.  In  multiparous  women  the  cervix 
becomes  thick  and  blunt,  and  the  os  forms  a  transverse  sHt, 
admitting  the  tip  of  the  finger,  or  it  may  be  fissiu-ed  in  one 
or  more  places. 

Canal  of  the  Cervix. — This  is  continuous  above  with  the 
uterine  cavity,  with  which  it  communicates  at  a  narrow  part 
termed  the  os  intevnmn.  It  then  dilates,  but  again  becomes 
narrow  close  above  its  opening  into  the  vagina  kno-^Ti  as  the 
OS  externum.  Its  mucous  membrane  bears  a  longitudinal  ridge 
anteriorly  and  posteriorly,  and  secondary  elevations  slope  off 
from  them  obliquely.  This  forms  the  "  arbor  vitse.''  The 
epithelial  layer  is  single  and  ciHatecl  upon  the  ridges,  but 
columnar  without  ciha  between  them.     At  the  os  internimi  it 


22 


THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 


ceases,  and  the  mucous  membrane  of  the  uterus  begins.  At 
the  OS  externmn  it  also  ceases,  and  squamous  stratified  epithelium 
covering  papillte,  invests  the  vaginal  aspect  of  the  cervix. 
Racemose  glands  abound  in  this  mucous  membrane,  and  secrete 
a  clear  glairy  alkaline  mucus.  This  escapes  freely  from  the 
OS  externum  in  many  healthy  subjects,  and  was  once  taken, 
under  these  circumstances,  for  evidence  of  disease.  The  firm 
spherical  bodies  known  as  the  ovula  Nabothi,  and  often  found 
on  the  cervix  outside  the  os  externum,  are  generally  admitted 
to  be  retention-cysts.  They  do  not  in  themselves,  however, 
represent  a  severe  morbid  condition. 

In  the  description  of  the  ureters,  the  blood-vessels,  and  lastly, 
the  relations  of  the  pelvic  viscera,  as  detected  by  different 
methods  of  examination,  more  will  be  said  concerning  the 
anatomy  of  the  uterus. 

The  Fallopian  Tubes. — These  structures  must  be  described 
together  with  the  uterus,  because  they  are  really  a  part  of  that 
organ.     Moreover,  recent  clinical  and  surgical  experience  have 


Fig.  7. — 15j;()A!)  Lioamext  Cyst  above  the  Tube.     [Avthor.) 
A  similar  cyst  lies  below  the  tube.     {Museum  R.C.S.,  No.  4,583.) 

proved  that  the  Fallopian  tubes  play  no  mean  part  in  the 
physiology  and  pathology  of  the  female  organs,  and  therefore 
they  must  not  be  placed  last  in  the  list  of  these  organs  and 
dismissed  in  a  few  words. 

Peritoneal   Investment. — Each  tube  lies  between  the  layers 
of  the  broad  ligament,  which  are  reflected  over  its  upper  surface 


FALLOPIAN   TUBES. 


23. 


and  meet  along  its  lower  surface,  whence  they  are  continued 
downwards  towards  the  ovary.  The  serous  membrane  is  held 
on  to  the  tube  by  connective  tissue,  generally  a  little  tenser 
and  firmer  than  that  which  lies  between  the  layers  of  the  broad 
ligament  lower  down.  Still,  it  is  easily  stripped  off  from  the 
tube,  whether  by  design  or  accident.  The  thin-walled  cysts, 
so  common  in  the  folds  of  the  broad  ligament,  are  rare  along 
this  line  of  reflection  over  the  tube,  and  when  they  develop 
there  they  seldom,  if  ever,  grow  large  (Fig.  7).  The  ostium  of 
the  tube  opens  into  the  peritoneal  cavity.  Hence,  as  has  already 
been  explained,  there  is  a  free  passage  from  the  exterior  of 
the  body  through  the  vulva,  vagina,  uterus,  and  tube  into  the 
peritoneum.  The  surgeon  and  obstetrician  must  never  forget 
this  fact.  Fortunately,  inflammatory  processes  tend  to  close 
the  ostium,  and  thus  protect  the  peritoneum. 


Fig.  8. — Diagkam  of  the  UxEpaNE  Appexdages.     {Hcnlc.) 

Ut,  uterus.  0,  ovary.  /,  fimbria.  Fo,  ovarian  fimbria  of  the  tube.  Po, 
X)arovarium.  ip,  io,  infundibulo-pelvic  ligament.  Oa,  ostium  of  tube.  Od, 
isthmus  of  tube.  Od',  ampulla.  Lo,  ovarian  ligament.  Ll,  posterior  layer, 
cf.  broad  ligament. 

Parts  of  the  Fallo^mui  Tube. — The  Fallopian  tube  measures 
about  four  inches  in  length,  when  not  stretched  artificially.     It 


24     THE  SURGICAL  ANATOMY  OF  THE  FEMALE  ORGANS. 

is  seldom  or  ever  of  the  same  length  as  its  fellow.  It  becomes 
extended  to  an  extreme  degree  in  cases  of  simple  broad  liga- 
ment cysts  which  press  against  it.  The  first  inch,  from  the 
fissures  of  the  uterus  outwards,  is  straight  and  narrow ;  this  is 
known  as  the  isthmus.  The  remainder,  is  dilated  and  is  called 
the  ampulla.  This  terminates  externally  in  the  conspicuous 
and  characteristic  fimbriated  extremity,  which  surrounds  the 
ostium,  or  opening  of  the  tube  into  the  peritoneal  cavity. 

The  canal  of  the  tube  is  very  narrow  in  the  isthmus,  barely 
admitting  a  bristle,  and  is  narrowest  at  its  junction  with  the 
uterine  cavity.     Along  the  ampulla  the  canal  is  wider. 

Natural  Pateney  of  the  Camd  of  the  Tube. — There  can  be  no 
doubt  that  the  Fallopian  tube  is  natm^ally  patent.  The  ovum 
must  pass '  along  it.  In  menon-hagia,  clots  are  sometimes 
passed,  which  form  perfect  casts  of  the  uterine  cavity  and  the 
canal  of  both  tubes,  the  latter  appearing  as  two  long  strings. 
Vaginal  injections  (as  Dr.  Matthews  Duncan  has  shown)  may 
pass  into  the  peritoneal  cavity  and  set  up  peritonitis.  The 
rarity  of  this  accident  is  no  reason  why  its  possibility  should  be 
ignored.  Bizzozero  found  an  ascaris  in  the  right  tube,  whence 
it  had  escaped  through  a  fistulous  passage  in  the  rectum. 
Winckel  describes  a  case  where  a  calcified  ascaris  was  found  at 
the  back  of  the  uterus  and  left  appendages.  He  beheves  that 
it  might  have  passed  as  an  egg,  or  as  a  very  young  worm, 
thi'ough  the  tube,  in  the  cmTent  of  an  injection  of  du-ty  water. 

In  some  cases,  where  the  sound  has  been  apparently  thrust 
through  the  uterine  wall,  it  has  in  reality  passed  along  a  tube. 

The  Fimhriated  Extremity. — The  fimbriae  of  the  tube  form 
a  characteristic  cluster  of  light-red  laminated  wattles,  some- 
times short  and  thick,  sometimes  ragged  and  elongated.  The 
former  is  generally  seen  in  robust  or  well-nourished  patients. 
One  of  the  fimbri£e  is  much  longer  and  thinner  than  the  rest. 
This  is  the  ovarian  fimbria,  and  it  runs  on  to  the  tissue  of  the 
ovary.  It  is  a  good  guide  when  the  parts  are  altered  by  new 
growths — indeed,  the  fimbriae  altogether  are  excellent  land- 
marks. Unfortunately,  they  are  rapidly  obliterated  in  inflam- 
matory diseases  of  the  tube  itself,  and  this  may  cause  great 
confusion  to  the  operator.  The  ovarian  fimbria  is  extremely 
elongated  in  eases  of  simple  broad  ligament  cyst. 


FALLOPIAN    TUi^ES. 


25 


Accessory  Flmhvke  are  not  rare.  They  sometimes  appear  as 
small  reddish  tags,  Kke  adhesions,  springing  from  the  tube. 
In  other  cases,  as  in  the  specimen  here  figured  (Fig.   9),  they 


^Es;;^^^:::^!/ 


Fig.  9. — Accessoky  FiMBpa^  .suPvKounding  ax  Agce.s.soe,y  Ostium  ox  a 
Fallopiak  Tube.     {Author.) 

are  stout  and  abundant,  surrounding  an  accessory  ostium,  which 
may  be  perfectly  patent.  This  condition  is  teratological,  not 
pathological,  and  when,  for  example,  it  is  discovered  on  the 
opposite  side  to  an  ovarian  tumour,  it  does  not  in  itself  demand 
any  surgical  interference  on  that  side. 

The  Cannl  of  the  Tube. — This  is  lined  with  mucous  mem- 
]3rane,  which  bears  ciliated  epithelium,  and  is  said  by  most 
histologists  to  possess  no  glands.  In  the  ampulla,  towards  the 
ostium,  it  is  elevated  into  a  complicated  series  of  longitudinal 
folds,  which  are  permanent,  like  the  valvulse  conniventes  of  the 
intestine,  and  not  to  be  effaced  by  simple  distension,  as  Dr. 
Savage  has  shown.  When  the  tube  is  cut  across  during  an 
abdominal  section,  the  surgeon  must  remember  that  its  mucous 
membrane,  which  communicates  with  the  exterior  through 
the  utero-vaginal  canal,  and  may  be  in  an  unhealthy  condition, 
is  brought  into  immediate  contact  with  the  peritoneal  cavity. 
This  must  especially  be  borne  in  mind  when  the  fimbriated 
extremity  is   closed  by  adhesions,  so  that   the   peritoneum  is 


26  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

preserved  from  any  morbid  influx  from  the  tube  till  the  latter 
is  cut  through  by  the  operator. 

Sfnictior  of  the  Tube. — The  tube  essentially  consists  of 
muscular  walls  prolonged  from  the  uterine  tissue,  and  made 
up  of  an  outer  series  of  longitudinal  and  an  inner  of  circular, 
plain,  muscular  fibres.  The  peritoneum  lines  this  muscular 
tube  externally,  and  the  mucous  membrane  lines  its  canal. 
Some  writers  believe  that  a  special  sphincter  surroimds  the 
uterine  end  of  the  canal. 

Position  of  the  Fallopian  Tube. — Of  this  I  shall  speak  when 
discussing  the  position  of  the  ovary.  At  present  I  need  simply 
observe  that  the  direction  of  the  tubes  in  relation  to  the  uterus, 
as  represented  in  diagrams,  is  quite  unlike  any  position  which 
they  assume  diu-ing  Hfe. 

The  Ovaries. — The  precise  position  of  these  organs  in  the 
pelvic  cavity  has  been  much  disputed.  They  hang  downwards  to 
a  greater  extent  than  would  be  supposed  were  we  to  rely  on  stock 
diagrams  in  text-books.  The  outer  part  of  the  Fallopian  tube 
turns  downwards  external  to  the  ovary,  so  that  its  fimbriae 
embrace  to  a  certain  extent  the  outer  part  of  that  organ.  The 
ovarian  fimbria  runs  upwards  on  the  ovary,  not  downwards  to 
the  ovary,  as  usually  represented.  This  relation  of  the  tube  to 
the  ovary  accoimts  for  the  singular  shape  of  a  dropsical  tube^ 
which  curves  outside,  and  a  little  below  the  ovary,  and  also  for 
the  position  of  tlie  foetal  sac  in  cases  of  gestation  in  the  outer 
part  of  the  Fallopian  tube,  the  sac  lying  not  above  the  ovary, 
but  outside,  and  often  partly  below  it.  As  the  uterus  always 
leans  a  little  to  one  side,  the  ovary  on  that  side  hangs  more 
than  its  fellow,  which  is  held  almost  horizontally  between  the 
ovarian  and  the  infundibulo-pelvic  ligaments. 

The  ovary  is  connected  with  the  back  of  the  broad  ligament 
by  its  dense  and  tough  hilion,  which  is  invested  by  a  plexus  of 
veins,  the  btdb  of  the  ovari/.  As  the  tissue  of  the  hiluni  is 
continuous  with  the  connective  tissue  between  the  folds  of  the 
broad  ligament,  morbid  growths,  developed  in  its  substance, 
tend  to  buiTow  into  these  folds.  The  pavenelnjina  or  ovum- 
bearing  part  of  the  ovary,  hangs  behind  the  broad  ligament. 
It  is  connected  with  the  uterus  by  a  prolongation  of  the 
muscular  tissue  of  the  latter,  called  the  ocarian    Uijamcnt^  and 


OVARIES PARO"S'ARIUM — BLADDER.  27 

invested  by  an  elevation  of  the  peritoneum.  This  ligament  is 
an  important  landmark  when  the  surgeon  is  engaged  in  explor- 
ing the  appendages  during  an  operation ;  it  is  much  stretched 
in  cystic  disease  of  the  ovary,  and  generally  hypertrophied 
in  fibroid  disease  of  the  uterus. 

The  ovary  varies  greatly  in  appearance  according  to  age, 
health,  and  the  stage  of  the  menstrual  cycle  at  the  moment  that 
it  happens  to  be  examined.  The  shrivelled  ovaries  seen  in 
typical  dissecting-room  subjects,  must  not  be  considered  as  types 
of  the  ovary  of  a  child-bearing  woman.  The  surgeon  must  not 
take  a  ripe  follicle  full  of  blood,  or  a  plump  succulent  ovary 
of  the  kind  generally  found  in  robust  young  women,  for 
a  morbid  structure.  The  average  weight  of  the  normal  ovary 
is  at  least  a  hundred  grains  ;  I  believe  it  to  be  higher  in  young 
subjects.  Its  long  axis  is  a  little  over  two  inches,  its  short 
axis  one  inch,  its  thickness  quite  half  an  inch. 

The  blood-vessels  of  the  ovary  will  presently  be  described. 
The  main  ovarian  vessels  lie  close  to  the  outer  part  of  the  organ, 
after  passing  along  a  short  fold  of  peritoneum,  which  runs  from 
the  brim  of  the  pelvis  to  the  ovary,  and  is  termed  the  tiifnndi- 
buh-jx'hnc  ligament.  Drs.  Hart  and  Barbour  rightly  describe 
it  as  that  part  of  the  upper  margin  of  the  broad  ligament 
unoccupied  by  the  Fallopian  tube.  It  is  a  most  important 
structure  for  the  surgeon  to  study,  as  it  forms  the  outer  border 
of  the  ovarian  pedicle. 

The  Parovarium. — This  is  a  structure  of  high  scientific, 
but  of  little  practical,  interest,  except  when  the  seat  of  disease. 
It  appears  as  a  group  of  eight  or  ten  tortuous  vertical  white 
lines,  in  the  broad  ligament,  joining  a  horizontal  line  above, 
and  converging  as  they  run  into  the  hilum  of  the  ovary  below. 
The  parovarium  can  only  be  clearly  distinguished  by  holding 
the  appendages  up  to  the  light  after  their  removal. 

The  Female  Bladder. — There  can  be  little  doubt  that 
a  great  many  incorrect  notions  prevail  about  the  female  bladder. 
Students  usually  endeavour  to  dissect  a  male  subject,  and,  as 
a  rule,  take  more  pains  to  learn  the  anatomy  of  the  male  bladder 
and  uretlii'a  than  that  of  the  corresponding  parts  in  the  female. 
Hence,  throughout  their  future  career,  their  knowledge  of  the 
latter  may  remain  too  limited  to  be  of  any  practical  service. 


28  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

The  female  bladder  is  generally  described  as  being  more 
capacious  than  the  male  bladder ;  it  certainly  appears  to  allow 
of  more  distension  transversely  and  antero-posteriorly,  hence  it 
does  not  rise  out  of  the  roomy  female  pelvis  until  very  full. 
An  over-distended  bladder  forms  a  conspicuous  object  Avhen  seen 
from  the  abdominal  side,  in  the  course  of  an  ovariotomy,  or  any 
similar  operation.  It  appears  as  an  oval,  almost  perfectly  cen- 
tral cyst,  with  its  base  upwards,  projecting  from  the  most 
anterior  part  of  the  pelvic  cavity.  Although  so  characteristic, 
it  may  be  mistaken  for  part  of  a  tumour,  if  a  number  of 
spherical  secondary  cysts  lie  in  its  vicinity;  whilst  if  it  be  dis- 
placed, or  its  peritoneal  coat  altered  in  appearance  by  the 
results  of  adhesive  inflammation,  it  will  be  much  exposed  to 
injury.  Hence  the  necessity  for  catheterism  before  abdominal 
section ;  yet  some  operators  prefer  to  leave  the  bladder  distended, 
as  a.  landmark. 

The  flaccid  bladder  may  also  be  seen  in  the  com'S(i  of  an 
abdominal  section.  When  visible  under  these  circumstances,  it 
must  either  have  been  greatly  displaced  by  the  tumour,  or  else 
di'agged  upwards  by  the  operator.  Its  outline  and  its  thick 
walls  are  seen  through  the  peritoneum.  When  the  serous 
investment  is  torn,  its  characteristic  muscular  coat  is  exposed. 

It  is  probably  on  account  of  its  great  capacity  for  transverse 
and  antero-posterior,  rather  than  for  vertical  distension,  that  the 
female  bladder  suffers,  relatively,  little  disturbance  of  function 
after  the  clamping  of  a  thick  uterine  pedicle  close  to  the  pubes. 
It  is  true,  that  at  first,  there  is  often  great  vesical  irritation,  but 
this  may  be  due  to  other  causes  than  the  obstacles  in  the  way  of 
upward  distension.  The  cervix  being  ch'awn  up,  the  bladder 
can  readily  distend  backwards  as  it  fills  with  imne.  I  have 
noted  this  condition  after  hysterectomy.  The  patients  do  not 
appear  to  become  subject  to  prolapse  of  the  bladder. 

From  the  vaginal  aspect,  the  female  bladder  becomes  con- 
spicuous in  cystocele,  when  it  forms  a  globular  projection 
distending  the  vulva  and  covered  by  the  anterior  vaginal  wall. 
In  the  great  majority  of  cases,  this  condition,  pathologically 
speaking,  means  primary  hernial  disj)lacement  of  the  vaginal 
wall,  the  bladder  following  simj)ly  because  it  has  lost  its  natural 
support   behind.      I   have   traced    strong    family    histories    of 


BLADDER. 


29 


ing-uinal  and  femoral  hernia  in  several  cases  of  this  affection. 
Were  cystocele  clue  primarily  to  chronic  over-distension  of  the 
bladder,  it  would,  I  believe,  be  far  more  frequent.  In  pro- 
lapsus and  procidentia  uteri  the  bladder  undergoes  great  dis- 
placement, as  will  shortly  be  explained. 

Position  and  Relations  of  the  Bladder. — The  female 
bladder  lies  behind  the  pubes  (Fig.  6),  except  when  con- 
siderably distended.     Its  lower  portion,  as  well  as  the  upper 


Fifi.  10. — The  Right  Half  of  the  Bladdek  and  Utekuh,  with  a  Small 
Part  of  the  Vagina. 
The  natural  relations  have   been  displaced  to  show  the   connections  of  the 
bladder  with  the  uterus  and  anterior  vaginal  wall.     {Museum  R.C.S.,  Physio- 
logical Series,  No.  2,822.) 

part  of  the  m-ethra,  is  separated  fi-om  the  pubes  by  loose 
connective  tissue  containing  much  fat.  This  is  the  retropubic 
fat  of  Hart  and  Barbour.  This  loose  connective  tissue  allows 
of  a  considerable  range  of  motion.  The  fundus  is  invested 
with  peritoneum  ;  the  relations  of  that  serous  membrane  to  the 
bladder  will  be  described  later  on.  Laterally,  the  bladder  lies 
in  relation  with  the  recto-vesical  fascia,  some  loose  connective 
tissue  intervening.     Posteriorly,  the  bladder  is  connected  mth 


30  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

the  lowest  part  of  the  body  of  the  uteras,  the  cervix,  and  the 
vagina.  It  is  separated  from  these  sti-uctiires  by  abundant 
connective  tissue.  This  connection  of  the  bladder  with  the 
uterus  and  vagina  is  well  displayed  in  Fig.  10,  which  is 
taken  from  a  specimen  of  the  right  half  of  the  anterior  pehdc 
viscera  in  the  Museum  of  the  Eoyal  College  of  Surgeons 
{Physiologiccd  Scries,  No.  2,822).  The  true  relations  have 
been  entirely  displaced.  The  half-uterus  is  bent  backwards, 
and  the  right  appendages  placed  so  that  the  specimen  may  be 
conveniently  suspended.  The  bladder  is  pulled  forwards,  its  walls 
lying  farther  apart  than  is  natural  in  an  uncontracted  empty 
bladder,  being  separated  by  threads  of  silk  used  to  suspend  the 
specimen.  All  the  suspending  threads  have  been  omitted  in 
the  sketch.  The  vesico-uterine  fold  of  peritoneum  is  displayed, 
and  the  bladder  is  seen  to  be  very  closely  connected  to  the 
cer\'ix  and  the  anterior  vaginal  wall.  This  relation  of  the 
bladder  to  the  uterus  varies  in  different  subjects,  the  connective 
tissue  certainly  reaching  as  high  as  the  body  of  the  uterus  in 
many  subjects.  The  difficulty  of  fixing  the  precise  position  of 
the  so-called  os  internum  partly  accoimts  for  discrepancies  on 
this  subject  amongst  different  authorities. 

The  relations  of  the  bladder  to  the  connective  tissue  of  the 
pehds  must  be  remembered  in  connection  with  jielvic  cellulitis, 
and  with  minary  fistulae  in  the  region  of  the  cervix. 

Form  of  the  Bladder. — The  female  bladder  is  pyriform  when 
distended.  It  assumes  another  form,  according  to  some  autho- 
rities, when  in  the  act  of  contracting,  and  yet  another  when  it 
is  flaccid  and  empty. 

When  contracting,  the  bladder  remains  convex  at  the  fimdus 
at  first,  and  the  anterior  and  posterior  walls  gradually  approxi- 
mate.* 

As  the  bladder  empties,  the  fundus  tends  to  fall  in  so  as  to 
become  concave  externally  (Fig.  6).  It  is  received  in  the  cup- 
shaped  dilatation  of  the  lower  part  of  the  bladder,  formed  by 
the  faUing  apart  of  the  anterior  and  posterior  walls  during 
relaxation.      When   viewed    in    vertical    section    the    relaxed 

*  Dr.  Matthews  Duncan  and  other  authorities  dispute  this  assertion,  and 
consider  that  vesical  systole  is  a  far  more  passive  process  than  is  generally 
supposed. 


BLADDER URETERS.  31 

bladder  forms  with  the  urethra  a  Y.  One  arm  of  the  Y  lies 
anteriorly,  the  other,  generally  much  shorter,  lies  posteriorly. 
The  lower  part  of  the  Y,  representing  the  lowest  part  of  the 
bladder,  and  the  urethra,  is  bent  forwards,  so  as  to  form  with 
the  anterior  arm  an  angle  in  which  the  retro-pubic  fat  is 
lodged. 

In  prolapsus  uteri  the  lower  and  posterior  part  of  the  bladder 
comes  down  with  the  anterior  vaginal  wall.  The  upper  and 
anterior  part  remains  in  place  behind  the  pubes,  whilst  the 
urethra  passes  downwards  and  backwards.  The  catheter  being- 
introduced  in  that  direction  in  a  case  of  prolapsus  iiteri,  it  will 
be  found  that  the  instrument  can  be  passed  both  downwards  and 
upwards. 

The  Ureters. — The  course  of  these  ducts  from  the  kidneys 
to  the  pelvis  is  described  in  systematic  works  on  anatomy.  At 
the  pelvic  brim  the  left  ureter,  according  to  Grarrigues,  crosses 
the  iliac  vessels  somewhat  higher  up  than  the  right.  Thus  the 
left  generally  lies  in  front  of  the  lowest  part  of  the  common  iliac 
artery,  the  right  passing  in  front  of  the  beginning  of  the  external 
iliac.  About  this  region  the  ureter  is  in  danger  of  injury  during 
the  separation  of  strong  adhesions  in  ovariotomy,  especially 
when  a  large  sessile  tumour  has  burrowed  under  the  peritoneum. 
The  ureter  is  a  structure  not  always  easy  to  recognize  when 
exposed  during  an  abdominal  section,  and  such  exposure  is 
most  likely  to  occur  in  cases  where  the  relations  of  the  tumour 
to  the  peritoneum  are  abnormal. 

The  course  of  the  ureter  in  the  pelvis  has  been  minutely 
described  by  many  living  writers,  especially  in  Grerman  and 
American  works.  Each  ureter  runs  downwards  and  somewhat 
backwards  along  the  pelvic  wall,  till  about  half  an  inch  above  the 
spine  of  the  ischium.  In  this  part  of  its  course  it  lies  behind  the 
outermost  part  of  the  broad  ligament,  quite  out  of  danger  durino- 
oophorectomy.  Close  above  the  spine  of  the  ischium  the  ureter 
turns  inwards,  and  passes  downwards  and  forwards.  Here  it 
passes  under  the  base  of  the  broad  ligament,  through  the  con- 
nective tissue  of  the  pelvis,  and  is  crossed  by  the  uterine  artery, 
which  runs  inwards  towards  the  uterus.  It  is  separated  from 
the  artery  by  some  of  the  veins  of  the  plexus  in  this  neighbom-- 
hood.     In  this  forward  course  the  ureter  runs  about  half  or 


32 


THE    Sl'RGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 


three-fifths  of  an  inch  outside  the  cer^dx,  passing  to  the  front 
of  that  structure.  Thence  the  ureter  descends  along  the  side  of 
the  upper  part  of  the  vagina,  turns  inwards  and  enters  the 
bladder.  It  runs  obliquely  do^vTiwards  and  inwards  for  at  least 
half  an  inch  through  the  vesical  walls,  opening  at  one  extremity 
of  the  base  of  the  trigone. 

These  relations  are  of  high  importance ;  unfortunately  they 
are  often  disturbed  by  various  abnormal  influences.  Hence  the 
minute  details  found  in  the  works  of  several  writers  are  not 
implicitly  trusted  by  practical  authorities.  The  ureter,  as  it 
runs  through  the  healthy  pehdc  connective  tissue,  is  easily  dis- 
placed, so  that  in  some  operations  the  fingers  may  push  it  out 
of  or  into  danger,  and  in  others  it  may  be  dragged  into  the 
jaws  of  forceps,  or  into  the  loops  of  ligatures  and  ccrasem's. 
"WTien  cancerous  or  inflammatory  infiltrations  exist,  the  ui'eter 
becomes  fixed,  grave  complications  may  result,  and  its  relations 
are  liable  to  become  deranged. 

This  diagram  illustrates  the  normal  relations  of  the  cer^•ix, 
the  ui^ethra,  and  the  ureters.      The  measurements  are  given  in 


3.CM 


4. CM 


2.5-3  CM 


Fui.  11. — The  Xokmal  Relations  of  the  Cei;vix,  the  Uketeus,  and  the 
Urethra.     {Eegar  and  Kaltcnbach. ) 

The  distance  from  the  cervix  to  the  orifice  of  the  ureter  is  .3  centimetres  ;  from 
the  orifice  of  the  m'eter  to  the  vesical  orifice  of  the  urethra,  4  cm.  ;  between  the 
orifices  of  the  ureters,  2 '5  to  3  cm.  The  course  of  the  uruters  through  the 
vesical  walls  is  indicated. 

centimetres  (one  centimetre  is  nearly  two-fifths  of  an  inch,  four 
centimetres  a  little  over  one  inch  and  a  half  j. 

The  proximity  of  the  ureter  to  the  cervix  must  especially  be 
borne  in  mind  during  supra-vaginal  hysterectomy  and  Porro's 


LKETERS PELVIC    PERITONELM.  33 

operation,  laparo-eljtrotomy,  supra-vaginal  amputation  of  the 
cervix,  and  any  form  of  total  extirpation  of  the  uterus.  Its 
course  along  the  upper  part  of  the  side  of  the  vagina  and 
through  the  walls  of  the  bladder  must  be  remembered  in  asso- 
ciation Avitli  urinary  fistulse  high  up  the  vagina,  especially  if 
laterally  placed.  Morison  Watson  asserts  that  the  ureters 
reach  as  low  as  the  middle  of  the  anterior  vaginal  wall.  It  is 
e^ddent  that,  in  operations  for  fistulse,  a  sutm^e  may  obstruct  the 
portion  of  one  ureter  which  runs  thi'ough  the  vesical  walls. 

The  Pelvic  Peritoneum. — The  arrangement  of  the  peri- 
toneal folds  in  the  female  pelvis  is  described  with  great  minute- 
ness in  most  of  the  larger  text-books  of  regional  anatomy,  and 
in  several  standard  works  on  the  diseases  of  women. 

The  parietal  layer  of  peritoneum  is  reflected,  a  little  above 
the  symphysis  pubis,  on  to  the  fundus  of  the  bladder,  when 
that  organ  is  empty.  When  much  distended,  the  fundus 
pushes  up  the  peritoneum,  leaving  a  distinct  space  uncovered 
by  serous  membrane  between  the  reflection  of  the  peritoneum 
on  to  the  parietes  and  the  symphysis.  This  fact  is  of  great 
importance  in  relation  to  supra-pubic  lithotomy. 

The  peritoneum  passes  from  the  fundus  to  the  posterior 
surface  of  the  bladder.  It  is  thence  reflected  on  to  the  anterior 
surface  of  the  uterus,  at  about  the  level  of  the  os  internum, 
passing  over  the  connective  tissue  which  separates  the  cervix 
from  the  bladder.  This  arrangement  of  peritoneum  forms  the- 
reHlco-uterine  pouch.  The  pouch  is  deep,  and  runs  almost 
vertically  downwards  when  the  bladder  is  in  systole  or  much 
distended.  Most  diagrams,  in  dissecting-room  manuals,  repre- 
sent this  pouch  as  though  it  were  constantly  deep.  This  error 
may  cause  difficulty  to  the  operator  during  an  abdominal 
section.  When  he  recognizes  a  distended  bladder,  there  is  no 
necessity  for  him  to  trouble  about  the  pouch.  The  bladder 
will,  however,  be  most  probably  empty.  Then  the  pouch,  in 
many  cases  of  tumour,  will  be  difficult  to  recognize.  It  is 
quite  effaced  by  pushing  the  uterus  backwards.  AVTien  the 
uterus  lies  natiu-allj^  with  its  fundus  bent  forwards,  the  pouch 
will  form  a  simple  reflection  of  peritoneum  running  almost 
directly  backwards,  and  not  downwards  as  in  Douglas's  j'jonch. 
The  vesico-uterine  pouch  does  not  lodge  small  intestine. 

1) 


r- 


34  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

All  the  peritoneal  folds  above  described  are  loosely  connected 
with  the  parts  which  they  invest ;  hence  they  are  very  liable 
to  be  torn  away  in  separating  adhesions  from  the  front  of  a 
pelvic  abdominal  tmnoui*,  or  to  be  so  displaced  as  to  confuse 
anatomical  relations.  The  muscular  coat  of  the  bladder  is, 
fortunately,  easy  to  recognize,  so  that  when  it  is  exposed  the 
sui'geon  at  least  may  see  what  he  has  done  and  where  he  is. 
Unfortunately,  in  many  of  these  perilous  cases  of  anterior 
pehdc  adhesions,  the  serous  coat  of  the  bladder,  already  adherent 
to  the  tumour,  is  likewise  adherent  to  the  muscular  coat,  so 
that  dimng  any  kind  of  traction  on  the  former  coat  the 
latter  is  pulled  up  Math  it  and  possibly  lacerated,  as  I  have 
witnessed,  or  else  di*agged  up  into  the  wire  loop  of  a 
serre-noeud. 

The  above  important  facts  teach  that  the  sm^geon  should 
faithfully  study  the  anatomy  of  the  anterior  part  of  the 
pelvic  peritoneum,  and  remember  that  it  presents  quite  other 
characters  than  those  of  a  Douglas's  pouch  on  a  small  scale. 

The  Uterine  Peritoneum. — The  peritoneimi,  passing  up- 
wards from  its  reflection  on  to  the  uterus  at  the  level  of  the 
OS  internum,  invests  the  anterior  part  of  the  body,  the  fundus, 
the  posterior  part  of  the  body,  the  supra-vaginal  part  of  the 
cervix,  and,  lastly,  the  upper  part  of  the  back  of  the  vagina. 
Thence  it  passes  upwards  over  the  rectum  and  sacrum. 

The  uterine  peritoneum  or  serous  coat  of  the  uterus  is  closely 
and  firmly  adherent  to  the  muscular  coat,  yet  it  is  occasionally 
detached  during  the  separation  of  adhesions.  In  one  case,  at 
least,  of  an  ovarian  cyst  which  had  forced  its  way  between  the 
layers  of  the  broad  ligament,  I  observed,  during  the  operation, 
that  the  cyst  had  detached  the  peritoneum  from  the  back  of  the 
uterus  as  far  as  the  fundus. 

Douglas's  Pouch. — The  reflection  from  the  vagina  on  to 
the  back  of  the  pelvis  forms  the  well-known  Boxf/la-s^s  ^ioitch. 
f  The  lower  limit  of  the  line  of  reflection  is  variable.  It  is 
greatest  towards  the  left,  and  generally  invests  a  little  over  one 
inch  of  the  vagina,  but  may  descend  much  lower.  Laterally, 
the  pouch  is  bounded  above  by  the  utero-sacral  ligaments. 
These  structiures,  it  must  be  remembered,  can  be  distinguished 
by  digital  exploration  of  the  rectum. 


Douglas's  pouch — broad  ligament.  35 

Douglas's  pouch  cannot  be  effaced  by  any  natui-al  altera- 
tion of  position  of  the  surrounding  structures.  It  is  easily 
explored  during  an  abdominal  section,  provided  that  it  be  not 
closed  in  by  adhesions  of  any  kind.  In  a  simple  ovariotomy 
its  characteristics  may  readily  be  distinguished  by  digital 
exploration,  which  the  operator  must  never  omit  even  in 
the  simplest  operation  of  this  kind.  Owing  to  the  dependent 
position  of  the  lower  limit  of  the  pouch,  blood,  serum,  or 
any  other  flidd  escaping  from  adjacent  structures  is  apt  to 
collect  there.  Hence  it  is  into  the  bottom  of  the  pouch  that 
the  drainage-tube  is  generally  inserted.  In  more  complicated 
operations,  when  the  surface  of  the  peritoneum  is  altered  by 
morbid  changes,  the  exploration  becomes  a  matter  of  difficulty. 
Intestine  lying,  free  or  adherent,  deep  down  in  this  pouch 
cannot  always  be  distinguished  from  peritoneum  by  touch 
alone.  The  peritoneum  constituting  Douglas's  pouch  is  not 
very  firmly  connected  with  the  structures  which  it  invests 
below  and  behind  the  uterus,  and  may  be  damaged  during 
the  separation  of  deep  adhesions. 

Lateral  Disposition  of  the  Pelvic  Peritoneum.— 
The  Broad  Ligament. — The  reflection  over  the  fundus 
extends  along  each  Fallopian  tube,  and  outwards  and 
backwards  over  the  ovarian  vessels.  The  layers  of  peritoneum 
meet,  after  investing  the  tube,  to  form  the  broad  ligament. 
The  fold  over  the  ovarian  vessels  is  slight,  yet  well  marked, 
and  is  known  as  the  infundibulo-pekic  ligament  (page  27).  A 
knowledge  of  this  structure  is  of  great  importance  for  the 
ovariotomist,  especially  in  relation  to  ligature  of  the  pedicle. 
It  is  extremely  easy  to  recognize,  on  account  of  the  pampini- 
form plexus  of  veins,  which  is  conspicuous  even  in  the  normal 
condition. 

The  layers  of  the  broad  ligament  enclose  the  parovarium,! 
and  several  arteries,  veins,  and  nerves  ;  the  precise  natiu-e  of  its 
lymphatic  supply  is  disputed.  The  folds  are  closely  applied  ( 
between  the  tube  and  the  ovary.  This  part  of  the  broad  ligament 
has  been  termed  the  mesosalpinx.  The  surgeon  must  remember 
that  it  is  not  the  whole  of  the  ligament  as  understood  by 
most  authorities.  Below  the  level  of  the  ovary,  the  layers  sepa- 
rate and  pass  to  the  sides  of  the  pelvis.     The  pelvic  conneciive 


36     THE  SURGICAL  ANATOMY  OF  THE  FEMALE  ORGANS. 

tissue  fills  the  space  formed  by  the  parting  of  the  layers.  This 
tissue  can  be  felt  as  a  tense  band,  running  from  the  uterus  to 
the  side  of  the  pelvis,  on  digital  exploration  of  the  vagina. 
When  the  rectum  is  explored,  the  back  of  the  broad  liga- 
ment can  be  reached.  This  is  an  impossibihty  in  vaginal 
examination. 

The  lower  limits  of  the  broad  ligament  are  not  easy  to  define 
fi'om  the  al  idominal  aspect ;  the  separation  of  the  layers 
immediately  below  the  ovary,  which  projects  behind  the 
posterior  laj'er,  is,  however,  evident.  The  precise  position 
of  the  upper  part  of  the  broad  ligament  is  very  hard  to 
define.  It  depends  entirely  on  the  position  of  the  tube.  I 
have  referred  to  this  subject  at  page  26. 

The  layers  of  the  broad  ligament  are  often  separated  by 
tumours  which  push  in  between  them,  either  from  the  direction 
of  the  ovary,  as  in  many  papillomatous  ovarian  tumom-s,  or 
from  the  uterus,  as  in  fibroid  tumom'S.  In  the  former  case 
there  will  be  difficulty  in  making  a  good  pedicle.  In  the  latter, 
oophorectomy  may  be  dangerous,  as  the  broad  Hgament  no 
longer  forms  a  sheet-hke  structure,  but  often  becomes  a 
pj'ramidal  body  with  its  base  towards  the  uterus,  highly 
unsuited  for  the  safe  apphcation  of  the  ligatm-e. 

Pelvic  Fascia,  Connective  Tissue,  Muscles,  and 
Nerves. — The  anatomy  of  these  important  structm-es  bears 
more  upon  science  and  clinical  medicine  than  on  operative 
surgery.  Any  direct  relations  between  sui'gical  proceedings 
and  special  peculiarities  in  the  disposal  of  the  fascia  and  con- 
nective tissue  "^Aill  presently  be  noted  in  the  description  of  such 
proceedings.  It  would  be  impossible  for  me  to  describe  in 
detail  the  arrangement  of  the  pehdc  fascia  and  connective  tissue 
without  mentioning  numerous  conflicting  opinions  of  different 
^^Titers,  and  this  I  could  not  do  without  wandering  from  the 
object  of  this  work.  The  prn'neum  T\dll  be  described  in  associa- 
tion with  operations  for  its  repair  when  lacerated. 

JTu-sch'.'i. — The  vulvar  and  perineal  muscles  are  described  with 
quite  sufiicient  accuracy  for  all  practical  pm-poses  in  general 
text-books  on  anatomy.  The  pecuHarities  of  the  anterior  part 
of  the  levator  ani  muscle  in  the  female  will  be  noted  in  the 
chapter  on  the  Methods  of  Pelvic  Exploration.     The  muscular 


PELVIC    NERVES    AND    ARTERIES.  '37 

apparatus  of  the  pelvis  is  of  great  importance  in  relation  to 
several  clinical  problems. 

Nerves. — The  observations  which  I  have  just  made  with 
regard  to  the  muscles,  apply  to  the  pelvic  nerves.  The  external 
organs  are  almost  exclusively  supplied  by  branches  of  the  pudic 
nerve,  the  internal  by  branches  of  the  sympathetic,  mostly  from 
the  hypogastric  plexus. 

Pressure  on  a  healthy  nerve  during  exploration  of  the  pelvis 
of  course  produces  pain,  which  may  be  mistaken  for  evidence  of 
disease.  This  kind  of  error  is  most  likely  to  occur  when  the 
finger  is  pressed  against  the  posterior  vaginal  fornix  in  a  patient 
with  a  small  or  shallow  pelvis,  so  that  one  of  the  cords  of  the 
sacral  plexus  is  squeezed  between  the  sacrum  and  the  finger. 
Schultze  was,  I  beheve,  the  first  to  indicate  this  fact.  I  have 
verified  it  repeatedly. 

Vessels  of  the  Pelvis. — The  distribution  of  the  vessels 
of  the  pelvis  involves  many  subjects  of  direct  interest  to  the 
surgeon. 

Arteries  of  the  Pelvis. — The  common  and  external  iliac 
arteries  are  covered  by  peritoneum.  The  operator  may  come 
dangerously  near  them  when  separating  adhesions  between  an 
ovarian  tumour  and  the  brim  of  the  pelvis.  I  have  known  the 
external  iliac  to  be  wounded  under  these  circmnstances.  The 
ureter  lies  under  the  peritoneum,  close  to  the  division  of  the 
common  iliac  artery  (page  31)  ;  thus,  care  must  be  taken  not  to 
mistake  it  for  a  blood-vessel  when  pelvic  adhesions  are  separated. 

The  Ovarian  Artery. — This  long  vessel  arises  from  the  aorta 
high  above  the  pelvis,  descends  behind  the  peritoneum,  and 
enters  the  broad  ligament  in  company  with  its  vein.  Before 
reaching  the  ovary  it  lies  in  the  free  border  of  the  broad 
ligament,  external  to  the  Pallopian  tube ;  this  portion  being  the 
infundibulo-pelvic  ligament  (see  pages  27,  35).  In  ovarian  cystic 
disease  this  ligament  becomes  much  hypertrophied  and  its  ves- 
sels enlarged.  It  then  appears  as  a  conspicuous  fold,  running 
from  the  brim  of  the  pelvis  on  to  the  pedicle.  The  pampini- 
form plexus  of  veins  can  be  seen  thi-ough  the  peritoneum,  and 
strong  pulsations  of  the  artery  can,  as  a  rule,  be  distinctly  felt. 
It  is  here  that  the  vessels  are  secured  when  the  outer  border  of 
the  pedicle  is  tied  separately,  as  will  presently  be  described. 


88  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

The  nature  of  tliis  infiindibiilo-pelvie  ligament  renders  ligature 
of  the  ovarian  artery  comparatively  easy  at  this  point.  Should 
the  divided  artery  slip,  as  may  readily  occur  when  the  outer 
border  of  the  pedicle  is  not  secured,  the  proximal  end  retracts, 
and  A^•ill  he  found,  after  death,  high  up  in  the  connective  tissue 
behind  the  peritoneum,  surrounded  by  clots  and  fluid  blood.  In 
pyjiemic  affections  of  the  pelvic  organs,  the  connective  tissue, 
to  which  I  have  just  referred,  is  liable  to  suppurate.  I  have 
seen  this  condition  in  a  case  where  a  patient  mth  a  large  fibroid 
tumour  of  the  uterus  died  after  a^^Ilsion  of  a  mucous  pol_)"pus. 
There  was  a  suppurating  track  along  almost  the  entii-e  course 
of  the  ovarian  vessels  above  and  below  the  pelvis. 

The  distribution  of  the  ovarian  arteries  will  be  described  in 
speaking  of  the  arterial  supply  of  the  internal  organs.  The 
branches  of  the  internal  iliac  pursue  a  course  which  is  described 
in  text -books  on  anatomy.  Only  such  as  directly  bear  on  the 
subject  of  the  manual  need  here  be  noted. 

The  Arteries  of  the  Vagina  and  Internal  Organs. — 
The  caginuJ  arteviea,  two  or  thi^ee  in  number,  are  given  off 
from  the  anterior  division  of  the  internal  iliac,  or  one  or  more 
of  them  may  be  branches  of  the  uterine  or  middle  haemon-hoidal. 
They  mn,  in  the  pelvic  connective  tissue,  to  the  side  of  the 
vagina,  where  their  branches  inosculate  freely  with  each  other, 
^'ith  their  fellows  on  the  opposite  side,  and  \\dth  perineal  vessels 
below.  From  above,  tortuous  branches  fi'om  the  artery  of  the 
cervix,  a  branch  of  the  uterine  artery,  communicate  with  the 
^'aginal  arteries,  often  on  both  vaginal  walls,  so  as  to  fomi  a 
vertical  (izy(joH  artery  of  the  vagina  (Fig.  12,  h,  p.  42),  anterior  and 
posterior.     Thus  the  vagina  is  well  supplied  with  blood-vessels. 

The  orarian  artery  (Fig.  12)  becomes  very  tortuous  when  it 
reaches  the  infundibulo-pelvic  ligament  (see  pages  27,  35,  37), 
and  this  tortuousness  increases  as  it  passes  between  the  layers 
of  the  broad  ligament,  below  the  level  of  the  ovary,  upwards 
and  inwards  to  the  upper  part  of  the  body  of  the  uterus. 
Before  reaching  the  uterus  it  divides  into  two  branches;  the 
upper  supplies  the  fundus,  the  lower  anastomoses  with  the 
uterine  artery,  which  passes  vertically  upwards  to  meet  it. 

The  branches  of  this  artery  are  nimierous.  Several  small 
arteries  run  to  the  dilated  outer  part  of  the  Fallopian  tube, 


OVARIAN  ARTERY UTERIXE  ARTERY.  39 

supplying  the  fimbrise.  Half-a-dozen  short,  tortuous  branches 
of  wide  calibre  supply  the  ovary  itself,  entering  that  organ 
through  the  hilum.  Two  or  three  branches  run  across  the 
broad  ligament  to  the  inner  two-thirds  of  the  Fallopian  tube, 
and  the  round  ligament  receives  a  special  branch. 

In  ovariotomy  and  allied  operations  on  the  uterine  ap- 
pendages, the  ovarian  artery  is  divided  in  two  places.  It 
must  be  cut  through  at  the  outer  border  of  the  pedicle,  where 
it  lies  in  the  infunclibido-j^elvic  ligament,  and  also  at  the  point 
where  it  crosses  the  line  of  ligature  of  the  pedicle — that  is,  in 
the  middle  of  its  course  towards  the  uterus,  between  the  layers 
of  the  broad  ligament.  Hence  a  complete  segment  of  the 
artery  is  cut  away,  and  may  be  easily  detected  on  examining 
the  tumour  after  operation.  It  will  be  found  between  the 
layers  of  the  broad  ligament,  running  to  the  cut  border  of  that 
peritoneal  fold  from  the  stump  of  the  infundibulo-pelvic  liga- 
ment, which  must  be  looked  for  on  the  surface  of  the  tumour 
close  to  the  ovarian  fimbria  of  the  Fallopian  tube. 

This  free  supply  of  arteries  to  the  broad  ligament,  and  the 
shortness  of  secondary  branches,  account  for  the  free  haemor- 
rhage which  occurs  when  the  Hgament  is  wounded  or  split  in  an 
operation  on  the  internal  organs,  especially  through  faulty  tying 
of  the  ligatm'e.  It  is  evident  that  the  main  trunk  of  the  ovarian 
artery  will  bleed  as  much  from  its  distal  as  from  its  proximal 
end,  if  not  secm-ed.  The  ligature  applied  to  the  outer  border 
of  the  pedicle  secures  the  ovarian  artery  as  it  lies  in  the  infundi- 
bulo-pelvic Hgament.  The  ligature  which  secures  the  inner 
half  of  the  pedicle  will,  or  should,  hold  firm  the  distal  part  of 
tlie  ovarian  artery,  which  communicates  fi'eely  with  the  uterine. 
It  is  self-evident  that,  if  either  of  the  above-named  ligatm-es  be 
inefficient,  the  consequent  haemorrhage  must  needs  be  perilous 
in  the  extreme.  The  division  of  the  ovarian  artery  into  two 
large  branches,  between  the  layers  of  the  broad  ligament,  close 
to  the  uterus,  is  a  source  of  peril  when  the  pedicle  of  an  ovarian 
tumour  is  very  short.  The  inner  ligature  may  directly  sur- 
round uterine  tissue  (see  page  17). 

The  uterine  artery  arises  from  the  anterior  di^dsion  of  the 
internal  iliac,  and  runs  downwards  and  inwards  in  the  pelvic 
connective  tissue  till  it  nearly  reaches  the  cervix,  when  it  crosses 


40  THE    SURGICAL    ANATOMY    OF    THE    FEMALE    ORGANS. 

the  m^eter  (see  page  31),  and  ascends  "between  the  layers  of 
the  broad  ligament  along  the  side  of  the  iiteiTis ;  in  this  part 
of  its  course  it  gives  off  the  artery  of  the  cervix,  which  is  very 
short,  rapidly  dividing  into  smaller  twigs.  The  uterine  artery 
then  becomes  exceedingly  tortuous,  and,  after  gi^ang  off  to  the 
substance  of  the  uterus  a  great  number  of  small  tortuous 
branches,  which  run  very  horizontally,  it  finally  anastomoses 
with  the  lower  branch  of  the  ovarian  artery  (see  Fig.   12). 

The  ultimate  distribution  of  the  branches  of  the  uterine 
artery  have  recently  been  described  with  great  minuteness  of 
detail  in  the  twenty-seventh  volume  of  the  Transactions  of  the 
Ohstdrical  Society  of  London,  by  Dr.  John  Williams.  Owing 
to  the  direction  of  the  vessels  which  traverse  the  muscular  wall, 
the  blood-current  runs  transversely  to  the  length  of  the  uterus, 
and  perpendicularly  to  its  surfaces  ;  so  that  a  ligature  ma}'  be 
placed  completeh^  around  the  uterus  without  affecting  the  circu- 
lation above  ancl  below.  Both  broad  ligaments  and  a  portion 
of  the  uterus  itself  must  be  ligatui^ed  before  the  blood-supjjly 
can  be  materially  checked.  This  condition  is  simulated  in  in- 
guinal hernia  of  the  uterus,  and  in  extreme  retroflexion  and 
retroversion,  which  represents  a  true  hernia,  the  utero-sacral 
hgaments  constricting  the  neck  of  the  sac.  In  procidentia,  a 
similar  obstruction  to  the  cu^culation  takes  place.  According  to 
Dr.  Williams,  the  most  acute  anteflexion  fails  to  cause  any 
impediment  to  the  uterine  circulation. 

In  supra- vaginal  amputation  of  the  uterus,  the  broad  liga- 
ments being  secui^ed  and  removed  and  the  cervix  held  firmly 
by  the  wire  of  a  Koeberle's  serre-nceud,  arterial  hsemon-hage 
is  well  checked  (Fig.  12,  A  A).  The  divided  uterine  ai-teries, 
often  much  dilated  in  fibroid  disease,  are  generally  seen 
gaping  on  each  side  of  the  cut  sui'face  of  the  cervix.  On  the 
other  hand,  when  we  remember  how  uterine  tissue  is  liable 
to  contraction  and  relaxation,  and  how  impossible  it  is  to  stop 
the  uterine  arterial  cii'culation  effectually  without  securing 
thoroughly  both  broad  ligaments  and  also  the  uterus  itself, 
the  dangers  of  the  intra-peritoneal  treatment  of  the  pedicle  of 
an  amputated  utems  become  evident.  HsemoiThage  from  a 
wound  of  the  uterus  or  from  a\Tilsion  of  the  pedicle  of  a 
subperitoneal  fibroid  growth  is  exceedingly  hard  to  check. 


UTERINE    ARTERY PELVIC    VEIXS.  41 

Lastly,  in  conditions  already  noted  (page  36),  it  may  happen 
that  in  removal  of  the  appendages  for  the  relief  of  menor- 
rhagia  from  uterine  fibroid  disease,  the  arteries  in  one  or  both 
of  the  appendages  cannot  be  effectually  secured ;  so  that  re- 
moval of  the  entire  uterus  above  the  cervix  is  necessary  to 
save  the  patient  from  death  from  haemorrhage.  These  matters 
will  again  be  considered  in  the  chapters  upon  the  Surgery  of 
the  Uterus. 

The  course,  position,  and  branches  of  the  uterine  artery  just 
before  it  reaches  the  cervix  should  be  borne  in  mind  in  relation 
to  operations  high  in  the  vagina,  especially  vaginal  extirpation 
of  the  uterus,  and  supra- vaginal  amputation  of'  the  cervix. 
From  a  glance  at  Fig.  12,  B  B,  it  will  be  evident  that  when  the 
broad  ligaments  are  secured  by  pressm-e-forceps  or  ligatures 
passed  through  the  vaginal  wound,  haemorrhage  dm-ing  re- 
moval of  the  uterus  will  be  as  entirely  controlled  as  when 
the  ligaments  and  the  cervix  are  secured  by  Kgatures  and 
the  serre-noeud  in  supra-vaginal  amputation. 

Artery  of  the  Cervix. — This  vessel  (Fig.  12,  e')  forms  a  short 
branch  of  the  uterine  artery,  given  off  at  the  point  where  the 
main  vessel  rises,  after  crossing  the  ureter,  to  meet  the  uterus  at 
an  acute  angle.  The  artery  of  the  cervix  runs  inwards  almost 
horizontally,  and  its  branches,  three  or  four  in  number,  proceed 
in  the  same  direction  to  enter  the  cervix  at  right  angles.  One 
branch  inosculates  by  two  twigs  with  its  fellow  to  form  the 
coronary  artery  of  the  cervix ;  this  lies  high  in  the  vaginal  part 
of  the  cervix,  and  is  in  danger  of  injuiy  dui'ing  Emmet's 
operation  and  other  procedures  in  the  neighbourhood.  Another 
branch,  anteriorly  and  posteriorly,  forms,  with  branches  of 
the  vaginal  artery,  the  azygos  arteries  of  the  vagina,  ah'eady 
noted. 

Veins  of  the  Internal  Organs. — For  full  information 
concerning  the  venous  supply  of  these  parts  I  must  refer  the 
reader  to  Savage's  and  Hart's  Atlases.  Yeins  accompany  the 
arteries,  and  also  form  plexuses.  Among  these  plexuses,  the 
pampiniform  plexus  and  the  bulb  of  the  ovary  are  of  the  most 
du'ect  practical  import.  Fhleholithes  are  frequent  in  the  large 
pelvic  veins.  They  sometimes  escape  by  ulceration  into  adja- 
cent tissues  and  organs. 


4'J  THE    SUKGICAL    ANATOMY    OF    THE    FEMALE    ORGAN'S. 


Vir..  12. 


VENOUS    PLEXUSES.  43 

Fig.  12. — The  Arteeies  of  the  Internal  Female  Organs,  seen  from 
Behinp.  [After  Hyrtl :  "•  Die  Corrosions  Anatomic  und  Hire  Ergehnisse" 
plate  xii. ) 

a,  Ovarian  artery,  a'  a'  a',  branches  to  the  ampulla  or  dilated  portion  of  the 
Fallopian  tube,  h',  branch  to  the  isthmus  of  the  tube,  c'  c'  c'  c'  c',  branches  to 
the  ovary,  h,  branch  of  ovarian  artery  to  round  ligament,  c,  superior,  and  d, 
inferior,  divisions  of  the  ovarian  artery  :  c  is  distributed  to  the  fundus  uteri  ;  d 
anastomoses  on  the  side  of  the  uterus  with  e,  the  strongly  twisted  uterine  artery. 
e',  artery  of  the  cervix  (I  have  often  seen  two  distinct  branches,  the  lower  passiu^f 
beneath  the  ureter).  Ur,  ureter  crossed  by  the  uterine  artery  below  the  broad 
ligament ;  it  here  lies  about  three-fifths  of  an  inch  from  the  cervix,  and  at  the 
level  of  the  os  externum,  e",  the  branches  of  the  artery  to  the  cervix  ;  one  of  the 
largest  of  these  branches,  anastomosing  with  its  fellow,  forms  the  circular 
or  coronarj^  artery  of  the  cervix,  sometimes  wounded  in  Emmet's  operation. 
/,  internal  iliac  artery,  giving  oW  g  g  g,  three  vaginal  arteries  (variable;  one  is 
often  given  off  from  the  uterine  artery),  h,  azygos  artery  of  vagina,  formed 
from  the  artery  of  the  cervix  and  branches  from  the  vaginal  arteries  on  both 
sides. 

A  A,  average  level  of  line  of  amputation  in  supra-vaginal  hysterectomy.  The 
trunks  of  the  right  and  left  uterine  arteries  will  lie  to  the  right  and  left 
of  the  uterine  stump.  B  B  shows  line  of  structures  secured  during  the 
operation  for  removal  of  the  entire  uterus  through  the  vagina.  It  may  pass 
through  the  undivided  trunk  of  the  ovarian  artery.  When  both  broad  liga- 
ments are  thus  secured,  and  the  cervix  separated  from  its  lower  connections, 
liEemorrhage  from  the  uterus  will  be  entirely  checked.  C  C,  line  of  structures 
divided  in  supra-vaginal  amputation  of  the  cervix,  when  the  lateral  connections 
of  the  cervix  are  detached.  The  branches  of  the  artery  to  the  cervix  cannot 
escape  division  ;  the  trunk  of  the  uterine  artery  is  generally  pushed  out  of 
danger  and  seldom  divided. 

The  pampiniform  plexus  accompanies  the  ovarian  artery.  It 
is  always  more  or  less  conspicuous  in  the  undivided  pedicle  of 
an  ordinary  multilocular  ovarian  cyst.  The  ovarian  artery  can 
be  felt,  or  even  seen,  pulsating  amidst  the  turgid  mass  of 
veins.  After  ligature,  a  large  thrombus  often  forms  on  the 
proximal  side  of  the  threads.  The  plexus  is  surrounded  by 
much  loose  connective  tissue,  which  may  inflame  and  even 
suppurate  if  damaged  by  careless  handling  in  abdominal 
operations  (see  also  pages  37,  38). 

The  bulb  of  the  ovary  is  a  venous  plexus  surrounding  the 
hilum  and  extending  to  the  ovarian  ligament.  It  communicates 
with  the  pampiniform  and  uterine  plexuses.  It  is  very  plainly 
seen  in  cases  of  oophorectomy,  when  the  ligature  is  tightened 
above  a  diseased  ovary. 

The   practical   surgeon   need    hardly   be   reminded   that   in 


44  THE    SURGICAL    ANATOMY    OF    THE    FEMAl-E    ORGANS. 

operations  about  the  uterus  and  its  appendages  he  must  be 
careful  not  to  transfix  any  veins  with  the  ligature. 

The  hull)  of  the  ragina  is  not  a  mere  plexus  of  veins,  but 
a  structure  composed  of  erectile  tissue  situated  on  one  side  of 
the  vulvar  orifice  of  the  vagina.  Each  bulb  extends  from  the 
clitoris  to  the  posterior  third  of  the  margin  of  the  vagina, 
ceasing  about  the  point  where  the  internal  labium  is  lost  on 
the  vulva.  The  bulbo-cavernosus  (accelerator  urinse  of  the 
male)  muscle  covers  it,  except  internally,  and  Cowper's  gland 
lies  behind  it.  Excepting  in  front,  it  corresponds,  practically 
speaking,  with  the  labium  minus.  Extensive  and  serious 
extravasations  may  follow  operation-wounds  of  the  veins  in 
the  vulva. 

The  Lymphatics  of  the  pelvis  are  of  great  importance  in 
the  clinical  study  of  diseases  of  women,  but  want  of  space  and 
other  circumstances  forbid  any  description  of  their  distribution 
in  this  manual. 


45 


CHAPTER  II. 

METHODS  OF  PELVIC  EXPLORATION. 

The  physical  examination  of  the  female  organs  is  conducted 
by  particular  methods  which  the  surgeon  must  carefully  practise, 
as  they  are  intimately  associated  with  some  of  the  most  impor- 
tant steps  of  certain  operations.  The  methods  in  question  are 
— simple  inspection ;  digital  exploration,  single-handed  or 
bimanual ;  inspection  aided  by  posture  ;  inspection  aided  by 
instruments,  such  •  as  the  speculum  and  volsella ;  and  the 
measurement  of  the  uterus  and  determination  of  its  degree 
of  mobility  and  relation  to  adjacent  parts  by  the  sound.  Some 
writers  add  the  dilatation  of  the  cervical  canal  by  sponge-tents 
to  the  above  methods. 

Inspection. — Only  the  external  organs  can  be  satisfactorily 
examined  by  simple  inspection,  which  may  be  most  readily  con- 
ducted when  the  patient  is  placed  on  her  left  side,  on  a  special 
couch,  or  on  a  table  about  three  feet  in  height.  The  knees 
must  be  well  drawn  up,  and  the  clothes  withdrawn  above  the 
nates.  The  lithotomy  position  is  not  essentially  necessary  for 
simple  inspection.  The  labia  cannot  be  parted,  to  any  extent 
serviceable  to  the  examiner,  by  abduction  of  the  thighs.  Certain 
legal  safeguards  must  not  be  overlooked  by  the  surgeon,  particu- 
larly when  the  patient  seeks  advice  more  or  less  at  the  behest 
of  others.  In  a  case  of  amenorrhoea  with  marked  anaemia  in 
a  reputed  virgin,  it  is  best  not  to  inspect  at  the  first  visit. 
Should  the  amenorrhoea  have  lasted  for  three  or  foiu'  months, 
abdominal  palpation  will  be  sufficient  to  detect  the  presence 
or  absence  of  an  enlarged  uterus  above  the  pubes.  In  cases 
of  suspected  ovarian  tumour  in  ^sirgins,  abdominal  palpation 
and  digital  exploration  through  the  rectum,  or,  in  obscure  cases. 


46  METHODS  OF  PELVIC  EXPLORATION. 

throiigli  the  vagina,  will  be  quite  sufficient,  without  any  recourse 
to  inspection. 

During  inspection  the  surgeon  must  pay  attention  to  the 
anatomical  points  noted  in  the  first  chapter.  He  must  be 
careful  not  to  make  mistakes  about  the  hymen ;  to  aid  in  the 
avoidance  of  such  errors,  I  have  abeady  described  the  anatomy 
and  varieties  of  the  hymen  and  carunculse  at  some  length.  The 
labia  and  all  the  other  vulvar  structures  may  be  well  developed 
when  some  of  the  most  important  internal  organs  are  malformed 
or  absent.  Discoloration  of  the  vulva  (see  page  3),  discharges 
of  blood,  mucus,  or  pus,  ulcers,  damage  to  the  perineum,  piles, 
fistulse,  and  fissures  must  not  be  overlooked.  Anal  or  rectal 
disease,  thus  discovered,  may  prove  to  be  the  cause  of  all  the 
patient's  symptoms.  Among  the  more  marked  or  serious  morbid 
conditions  which  may  be  detected  on  inspection  are — procidentia 
uteri,  inverted  uterus,  prolapse  of  the  vaginal  walls,  extreme 
elongation  of  the  cervix,  and  uterine  polypi  with  unusually  long 
pedicles. 

Digital  Exploration*  of  the  Vagina. — The  smgeon 
must  learn  how  to  conduct  this  kind  of  exploration.  Bimanual 
examination  is  a  method  of  greater  diagnostic  value,  but  it 
cannot  be  learnt  without  a  sound  practical  knowledge  of  digital 
exploration.  The  patient  should,  whenever  possible,  be  placed 
on  a  table  or  couch,  as  during  inspection  (see  page  45),  and  she 
should  also  be  prepared  as  for  bimanual  palpation,  in  the 
manner  shortly  to  be  described ;  in  any  case,  care  must  be 
taken  that  the  clothes  are  kept  out  of  the  way.  The  patient 
lies  on  her  left  side  wdth  her  left  shoulder  well  down,  and  not 
supported  by  the  left  elbow.  Her  body  must  be  bent  and  her 
knees  drawn  up.  The  stays  must  always  be  loosened,  the  drawers 
removed,  and  the  skiiis  of  the  dress  kept  backwards  and  above 
the  nates.  The  lower  extremities  and  hips  are  covered  by 
bedclothes,  or  a  shawl,  or  other  suitable  covering.  The 
patient's  confidence  is  necessary  in  every  stage  of  this  process, 
for,  even  when  she   is   tractable,  the  sui'geon  will  often  find 

*  After  some  consideration,  I  have  come  to  the  conclusion  that  "  exploration  " 
is  the  hest  term  to  employ  in  this  case.  I  have  discarded  all  italic  Latin  expres- 
sions, such  as  "■'  '^cr  vaginani"  and  '^ per  anuni."  They  serve  no  purpose,  either 
in  respect  to  science,  medicine,  or  delicacy. 


DIGITAL    EXPLORATION    OF    THE    VAGINA.  47 

Mmself  mucli  impeded  by  her  coiistant  tendency  to  straighten 
the  knees  and  draw  the  pelvis  away  from  the  part  of  the  couch 
on  which  it  should  lie.  The  surgeon  must  not  lose  her 
confidence  by  declaring  that  he  is  not  hurting  her  when  she 
complains  of  pain,  or  by  displaying  hurry,  roughness,  or  loss  of 
temper. 

The  surgeon's  finger-nails  must  be  well  trimmed,  for  a  long 
nail  is  in  any  case  liable  to  scratch  the  vaginal  mucous 
membrane,  so  as  to  cause  great  pain,  which  is  not  always 
transient.  Care,  of  course,  must  be  taken  that  the  nails  do 
not  carry  infection  from  a  previous  case ;  and  it  must  be  remem- 
bered, especially  in  hospital  practice,  that  chaj)s  or  agnails  on 
the  fingers  may  expose  the  surgeon  himself  to  danger.  The 
fingers  must  be  warm  ;  if  cold  they  are  apt  to  cause  great 
irritation. 

The  fore  and  middle  fingers  of  the  right  hand,  or  the 
forefinger  alone  in  case  the  vagina  be  evidently  very 
narrow,*  are  dipped  into  carbolized  oil  or  vasehne,  any 
superfluity  of  which  must  be  shaken  off  so  as  not  to  soil  the 
patient's  clothes.  The  left  hand  is  then  placed  on  the  patient's 
right  hip,  to  steady  her,  and  the  two  fingers  of  the  right 
hand  are  introduced.  Here  I  must  note,  before  proceeding 
further,  that  the  practice  of  pressing  the  left  hand  on  the 
abdomen,  at  this  stage  at  least,  is  objectionable.  In  order  to 
ascertain  the  actual  position  of  the  pelvic  organs,  the  surgeon 
must  not  attempt  to  push  them  down. 

The  two  fingers  should  be  directed  to  the  perineum,  and 
then  slipped  into  the  posterior  part  of  the  vulva.  The  anus, 
which  every  surgeon  should  be  able  to  detect  by  touch,  must  be 
avoided,  but  it  may  be  used  as  a  guide  to  the  parts  anterior  to  it 
in  position.  If  the  hairs  of  the  vulva  be  touched,  the  fingers 
must  be  raised  and  drawn  back,  so  as  to  search  for  the 
perineum,  for  any  attempt  to  introduce  the  fingers  between 
the  labia  anteriorly  will  probably  cause  some  of  the  hairs  to 

*  I  am  firmly  of  opinion  that,  in  the  systematic  examination  of  2:)atients  in  the 
out-patient  room,  two  fingers  should  be  employed  for  digital  exploration.  The 
beginner,  however,  will  find  it  more  convenient  to  introduce  the  forefinger  only. 
Likewise,  in  defining  any  swelling  or  structure  already  discovered  by  the  two 
fingers,  it  is  advisable  to  slip  the  middle  finger  out  of  the  vagina,  and  to  rely  on 
the  forefinger  alone. 


48  METHODS    OF    PELVIC    EXPLOKATION. 

be  pushed  upwards  against  the  tender  structui-es  within  the 
vulvar  orifice.  AVhen  the  fingers  enter  the  vagina,  they  are 
sUpped  upwards  till  the  posterior  fornix  is  reached.  As  they 
go  higher,  more  and  more  care  must  be  taken  lest  the  nails 
scratch  the  mucous  membrane,  and  lest  the  knuckles  of  the 
other  fingers  of  the  right  hand  bruise  the  vulva. 

The  surgeon  now  notes  what  the  fingers  can  detect.  They 
can  be  felt  to  part  the  anterior  from  the  posterior  wall  of  the 
vagina;  in  fact,  they  enter  no  true  cavity.*  Posteriorly,  the 
tissues  of  the  perineum,  the  coccyx,  and  the  lowest  part  of 
the  concavity  of  the  sacrum  can  be  felt ;  also,  a  little  laterally, 
the  limits  of  the  rectum,  which  must  not  be  mistaken  for  the 
edge  of  a  collapsed  cyst  or  for  a  prolapsed  and  diseased 
Fallopian  tube.  Scybala  in  the  rectum  are  readily  detected 
when  low  down,  and  then  can  be  recognized,  if  not  very 
hard,  by  their  property  of  pitting  on  pressm-e.  Of  course  they 
cannot  in  themselves  be  tender,  but  when  the  finger  presses  the 
recto-vaginal  septum  roughly  against  a  scybalous  mass,  pain 
will  be  felt  by  the  patient,  and  the  surgeon  may  fall  into  the 
error  of  mistaking  the  mass  for  a  sensitive  Hving  structm-e, 
normal  or  pathological.  When  scybala  lie  high  in  the  rectum 
they  cannot  be  diagnosed,  mth  surety,  by  the  finger  in  the 
vao-ina.  Whenever  scybala  are  found,  the  exploration  should 
be  repeated  after  the  rectum  has  been  cleared  by  an  enema. 

Laterally  the  border  of  the  sphincter  vaginae  may  be  de- 
tected, especially  when  there  is  some  soreness  about  the  vulva, 
causing  it  to  contract.  The  sphincter  is  by  no  means  a  powerful 
muscle.  A  cleft,  often  easily  distinguished,  separates  it  partially 
from  the  levator  ani.  The  well-known  tendinous  arch,  whence 
part  of  the  fibres  of  this  latter  muscle  arise,  is  readily  felt 
by  the  finger,  and  is  an  excellent  landmark.  The  contractions 
of  the  anterior  fibres  of  the  levatores  ani,  which  form  the  pubo- 
coccygsei,  or  homologues  of  the  levatores  prostatse  in  the  male, 
are  not  difficult  to  detect,  and  sometimes  resist  the  introduction 
of  the  fingers,  especialh'  when  there  is  inflammatory  pelvic  dis- 
ease or  fissure  of  the  anus.  It  will  be  observed  that  they  press 
^\ith  considerable  force  on  the  vagina  laterally.  After  the  fingers 

*  The  surgeon  must  rcnieniber  that  the  posterior  wall  of  the  \agina  lies  far 
below  and  anterior  to  the  concavitv  of  the  sacrum. 


DIGITAL    EXPLORATION PELVIC    MUSCLES.  49 

have  passed  above  tlLeir  level,  their  resistance  becomes  inappre- 
ciable. 

Not  only  can  the  levator  ani  be  detected,  but  the  obtni'ator 
internus  is  also  by  no  means  difficult  to  distinguish.  Dr. 
Schultze,  of  Jena,  was  among  the  first  to  note  this  fact, 
which  I  have  carefully  investigated,  and  can  fully  confirm. 
By  pressing  the  fingers  against  the  vagina  laterally,  above 
the  level  of  the  tendinous  arch  of  the  levator  ani,  the  muscular 
origin  of  the  obturator  internus  can  be  felt,  and  the  muscle 
on  the  right  side  can  be  made  to  contract  by  directing  the 
patient  to  rotate  the  right  thigh  a  little  outwards ;  it  can  also 
be  well  distinguished  during  extension  and  adduction.  Further 
backwards  and  upwards  the  pyriformis  may  be  reached,  in 
cases  where  the  pelvis  is  not  deep,  and  if  a  large  branch  of 
the  sacral  plexus  in  the  neighbourhood  of  this  muscle  be 
pressed,  considerable  pain  will  ensue.  Pressiu-e  towards  the 
pelvic  brim  laterally  and  somewhat  forwards  may  also  cause 
severe  pain,  the  obturator  nerve  being  touched  in  this  case. 

These  facts  are  of  practical  importance,  and  are  no  mere 
anatomical  curiosities ;  for  I  have  repeatedly  found  that  where 
sources  of  pain  or  nerve-irritation  are  present  these  muscles; 
are  most  readily  detected.  The  reader  will  be  best  able  tO' 
verify  this  for  himself  by  careful  and  gentle  exploration  in 
cases  where  pelvic  inflammation  or  fissure  of  the  anus  exists. 
The  contractions  of  the  pelvic  muscles  may,  on  the  other  hand, 
be  marked  during  the  first  vaginal  exploration  in  a  timid  patient 
not  subject  to  any  painful  local  disease.  The  hard  contracted 
muscles,  especially  the  obturator  internus,  may,  in  this  case,  be 
taken  for  an  inflammatory  deposit.  At  a  subsequent  exami- 
nation there  may  be  more  confidence,  hence  less  muscular  spasm. 
The  muscular  contraction  will  then  be  absent,  but  the  surgeon 
may  misinterpret  the  case  and  believe  that  an  inflammatory 
deposit  which,  as  he  believed,  existed  before,  has  disappeared. 

I  have  likewise  little  doubt  that  the  pain  caused  by  pressure 
of  the  fingers  on  large  nerves  is  not  unfrequently  taken  for 
evidence  of  disease.  The  surgeon  must  never  forget  that  many 
healthy  structures,  especially  nerves,  are  painful  on  pressure  ; 
nor  when  he  causes  pain  in  this  way  must  he  hurt  the  patient's 
feehngs  by  saying  that  "  it  is  nothing."     Lastly,  the  position  of 


50  METHODS  OF  PELVIC  EXPLORATION. 

the  pelvic  nerves  explains  how  they  may  be  affected  when 
siuTOuncled  hj  inflamed  connective  tissue  or  pressed  upon  by 
new  gro^nhs,  and  the  direction  of  the  radiation  of  pain  in 
any  case  mil  thus  become  comprehensible. 

In  the  front  of  the  vagina  the  fingers  will  detect  the  uretlira, 
like  a  cord  in  the  anterior  vaginal  wall  ;  the  bladder,  if  fairly 
distended  ;*  and  the  anterior  fornix,  or  reflection  of  the  anterior 
wall  of  the  vagina  on  to  the  cervix.  The  presence  of  hard 
deposit,  or  a  tumour  pressing  downwards,  or  an  enlarged  uterus, 
may  be  noted,  but  bimanual  examination  will  be  requii-ed  in 
these  cases. 

Most  important  of  all,  as  a  rule,  is  the  evidence  obtained  by 
the  fingers  as  to  the  condition  of  the  structures  in  the  neighbour- 
hood of  the  upper  limits  of  the  vagina.  Fii'st,  there  will  be  the 
vaginal  portion  of  the  cervix  uteri.  The  os  externum  at  least 
•can  easily  be  reached  unless  the  uterus  be  greatly  displaced,  as  in 
some  cases  of  fibroid  disease,  where  a  depression  in  front  of  the 
morbid  growth,  close  under  the  pubes,  is  sometimes  aU  that  can 
be  felt. 

The  cervix  forms  a  truncated  cone,  covered  with  soft  mucous 
membrane.  During  health  it  is  never  tender  to  the  touch,  and 
when  pain  is  produced  as  the  surgeon's  fingers  reach  it,  the  cause 
generally  lies  higher  up,  in  the  uterus  or  its  appendages  which 
are  disturbed  when  it  is  touched.  The  cervix  is  short  and  slightly 
flattened  antero-posteriorly  in  nulliparae,  but  thick,  tough,  and 
cylindrical  in  most  multiparse.  In  pregnancy  it  is  expanded, 
so  as  to  be,  as  it  were,  more  or  less  lostt  in  the  body  of  the  uterus 
as  gestation  advances ;  the  fingers  can  ascertain  this  condition. 
At  the  same  time  its  tissues  feel  very  soft.     When  the  uterus  is 

*  Sanger  has  detected  the  ureters  by  digital  exploration  of  the  vagina  in 
various  urinary  disorders.  He  saj's  that  they  cannot  be  felt  in  every  woman, 
but  are  frequently  to  be  made  out  during  pregnancy,  when  they  arc  hyper- 
trophied.  Dr.  Sanger  detected  the  ureters  in  eight  out  of  ten  cases  of  preg- 
nancy, but  has  never  felt  them  during  the  lying-in  period.  They  feel  about 
as  thick  as  a  goose-quill,  and  lie  in  front  of  the  upper  third  of  the  anterioi 
vaginal  Avail,  about  three-quarters  of  an  inch  below  the  cervix.  In  the  later 
months  of  pregnancy  they  can  be  pressed  against  the  fcetal  head.  (See  T/ie 
Year -Book  of  Treatment  for  1886,  page  222.) 

t  For  the  precise  nature  of  the  changes  of  the  cervix  during  jnegnancy,  the 
surgeon  must  consult  standard  text-books  on  midwifery.  (See  Matthews  Duncan, 
Edinburgh  Medical  Jaurnal,  March,  1859. ) 


DIGITAL    EXPLORATION THE    CERVIX.  51 

healthy,  the  cervix  can  be  gently  moved  backwards  and  forwards 
without  causing  pain. 

The  OS  externum  feels  like  a  small  circular  dimple  in  nulli- 
parae. In  women  who  have  borne  children  it  generally  forms  a 
transverse  slit,  often  wide  enough  to  admit  the  tip  of  the  fore- 
finger. Its  borders  then  appear  to  form  a  sharp  rim  siuround- 
ing  the  finger.  Fissures  are  very  frequent  in  women  who  have 
borne  children,  and  are  often  associated  with  aversion  of  the  tissues 
of  the  cervix.  The  lips  of  the  os  may  be  hypertrophied,  even 
to  an  extreme  extent.  It  is  important  that  the  presence  or 
absence  of  any  structure  protruding  from  the  os,  or  of  any  sign 
of  cancerous  ulceration,  should  be  ascertained  by  the  finger. 

In  normal  conditions  the  fingers  can  always  be  passed  com- 
pletely round  the  cervix ;  but  cicatrices  may  exist,  causing  an 
adhesion  between  its  surface  and  the  vaginal  mucous  membrane. 

When  there  is  difficulty  in  detecting  the  cervix,  so  as  to  lead 
to  a  suspicion  of  its  absence,  especially  when  a  small  dimple  only 
can  be  detected  at  the  upper  extremity  of  a  short,  wide  vagina, 
further  evidence  of  absence  or  imperfect  development  of  the 
uterus  can  only  be  satisfactorily  gained  by  bimanual  examina- 
tion. An  abnormality  of  this  kind  is  sometimes  wrongly  dia- 
gnosed. Thus,  an  inexperienced  practitioner  may  pass  a  finger 
into  the  rectum  by  mistake,  and,  feeling  the  cervix  through  its 
walls,  may  take  it  for  an  atrophied  uterus  not  communicating 
with  the  vagina  ;  or  may  recognize  it  as  the  cervix,  yet  believe 
that  the  vagina  is  occluded.  In  some  women  the  hymen  re- 
mains after  repeated  coitus  ;  its  borders  may  firmly  siuToand  the 
fingers,  so  that  as  they  pass  high  up  it  is  drawn  upwards  with 
them.  I  have  already  spoken  of  this  condition  in  describing 
the  hymen. 

When  the  sm-geon  has  examined  the  cervix  in  the  manner 
just  described,  he  must  on  no  account  be  in  a  hurry  to  introduce 
the  sound.  In  many  cases  it  may  be  dispensed  with  altogether, 
and  it  should  never  be  used  till  after  bimanual  examination. 
I  shall,  however,  return  to  this  subject  when  speaking  of  the  use 
of  the  sound. 

The  fingers  must  now,  after  careful  exploration  of  the  cervix, 
be  passed  into  the  posterior  cul-de-sac  or  posterior  fornix.  In 
ascertaining  its  depth,  the  fingers  being  necessarily  stretched  to 


52  METHODS  OF  PELVIC  EXPLORATION. 

their  utmost  extent,  especial  care  must  be  taken  lest  the  nails 
touch  the  mucous  membrane,  else  the  pain  so  caused  may 
entirely  mislead  the  surgeon.  In  health,  no  structure  can  be 
distinctly  felt  in  the  posterior  fornix.  Scybala,  or  the  border 
of  the  rectum,  may  be  taken  for  different  morbid  conditions,  in 
a  healthy  subject.  Cysts,  solid  un circumscribed  deposits,  well- 
detined  tiunours,  and  many  other  morbid  conditions,  may  here  be 
detected,  but  bimanual  examination  will  always  be  necessary 
to  confirm  diagnosis. 

On  each  side  of  the  cervix,  the  base  of  the  broad  ligament 
can  be  felt  by  pushing  the  vault  of  the  vagina  gently  upwards, 
taking  care,  once  more,  lest  the  nail  touches  the  mucous  mem- 
brane. It  feels  like  a  thin,  resistant  band,  but  is  never  markedly 
tense  in  health.  Morbid  thickening  is  very  frequent,  especially 
on  one  side.  A  healthy  ovary  can  never  be  detected  in  this 
manner. 

The  surgeon's  fingers  will  also  detect  any  foreign  body  lying 
in  the  vagina,  such  as  stems,  pessaries,  or  plugs,  introduced  by 
other  practitioners,  or  substances  slipped  in  by  the  patient 
herself.  The  condition  of  the  vaginal  mucous  membrane  must 
also  be  noted.  It  feels  abnormally  hot  in  some  local  inflam- 
matory diseases,  and  in  many  cases  where  the  temperature  of 
the  body  is  high.  Fistulous  communications  with  the  bladder 
and  rectum  may  be  explored  in  this  manner,  but  they  always 
need  the  use  of  the  speculmn. 

Precautions  in  Digital  Exj)loration. — The  surgeon  must  not 
hook  his  finger  forcibly  round  the  front  of  the  cervix  to  ascer- 
tain the  degree  of  mobility  of  the  uterus.  Should  any  inflam- 
matory deposit  exist,  this  practice  is  certain  to  cause  great  pain, 
and  may  set  up  fresh  inflammatory  changes.  Moreover,  the 
pain  may  be  mistaken  for  evidence  of  disease  of  the  cervix, 
whilst  in  reality  the  morbid  condition  lies  much  higher.  What 
is  generally  described  as  a  tender  cervix  really  signifies  pain  in 
some  deep  pelvic  structure  set  up  by  forcible  pressiu'e  on 
the  cervix,  which  is  itself  a  structure  possessing  a  very  low 
degree  of  sensitiveness. 

Simple  digital  exploration  of  the  pelvis  through  the  rectum 
will  be  considered  after  some  of  the  more  direct  methods  of 
examining  the  condition  of  the  female  organs. 


BIMANUAL    EXAMINATION.  53 

Bimanual  Examination. — This  is  a  method  of  perfecting 
diagnosis  widely  in  use  at  the  present  day,  and  of  the  highest 
value.  It  only  serves  its  purpose  when  properly  conducted, 
and,  as  it  is  indispensable,  every  surgeon  must  leam  how  to 
practise  it  skilfully  and  on  correct  principles. 

Some  practitioners  content  themselves  with  passing  the  left 
hand  over  the  hypogastrium  as  the  patient  lies  on  her  side,  and 
pressing  downwards,  whilst  the  right  fore  and  middle  fingers 
are  engaged  in  exploration  of  the  vagina.  This  kind  of  mani- 
pulation is  often  necessary,  especially  when  the  relations  of  an 
abdominal  tumour  to  the  pelvic  viscera  have  to  be  ascertained, 
but  it  is  not  what  is  understood  by  authorities  as  bimanual 
palpation.  The  state  of  the  uterine  appendages  and  the  lateral 
parts  of  the  pelvic  cavity  can  never  be  properly  explored  in  this 
way.  In  cases,  however,  where  pelvic  tumours,  especially  if 
small,  are  suspected,  much  maj^  be  found  out  by  this  lateral 
method  of  bimanual  examination,  if  carried  out  when  the  patient 
is  placed  first  on  her  left  and  then  on  her  right  side. 

Bimanual  examination  properly  signifies  simultaneous  explo- 
ration of  the  vagina  with  one  or  two  fingers  of  the  right  hand, 
and  pressure  on  the  lower  part  of  the  abdominal  walls  with  the 
left,  the  patient  lying  on  her  back.  The  surgeon  must  ascertain 
what  can  be  felt  between  his  hands. 

The  patient  must  be  placed  in  the  position  which  is  also  most 
convenient  for  examination  of  the  abdomen  alone.  She  must 
lie  evenly  on  the  couch  or  bed,  and  on  her  back.  A  pillow 
should  be  placed  under  the  head  and  shoulders,  and  the  knees 
must  be  drawn  up.  Care  must  be  taken,  if  the  patient  be 
examined  out  of  bed,  that  the  clothes  are  drawn  well  above  the 
epigastrium,  the  stays  taken  off  altogether,  the  upper  border  of 
the  petticoat  kept  as  low  as  the  pubes,  and  the  dress  which 
covers  the  knees  arranged  so  as  not  to  interfere  with  the 
surgeon's  right  hand  engaged  in  exploring  the  vagina.  It  is 
far  better  that  the  patient  should  be  in  bed,  wearing  only  a 
night-dress ;  then  she  will  be  most  at  her  ease,  and  there  will 
be  less  trouble  through  contractions  of  the  abdominal  muscles. 
Hence  the  same  medical  attendant  may  discover,  when  examin- 
ing the  patient  as  she  lies  in  bed,  what  he  has  failed  to  detect 
when   exploring   under   less   favoui'able  conditions.      In   some 


54  METHODS   OF    PELVIC   EXPLORATION. 

cases  an  aupestlietic  "will  be  required,  as  when  great  pain  must 
otherwise  be  produced,  or  when  the  absence  of  any  local 
disease  is  suspected,  yet  a  very  close  scrutiny  of  the  pelvic 
organs  is  necessary  for  the  final  justification  of  that  suspicion. 

The  right  hand  is  passed  towards  the  vulva  with  the  ulnar 
border  do'v^oiwards  and  the  thumb  extended.  The  fore  and 
middle  fingers  are  introduced  into  the  vagina,  the  others  are 
flexed,  whilst  the  thumb  is  kept  against  the  symphysis  pubis. 
I  am  strongly  of  opinion,  after  considerable  experience,  that  two 
fingers  should  be  introduced  whenever  possible.  The  middle 
finger  is  pushed  against  the  os  uteri,  the  forefinger  is  pressed 
against  the  anteiior  fornix  in  front  of  the  cervix.  This 
manoeuvre  tilts  the  body  of  the  uterus  forwards — in  fact,  it 
causes  anteversion,  so  that  the  fundus  is  brought  nearer  to 
the  abdominal  walls,  and  more  within  reach  of  the  other 
hand.  The  aim  of  this  part  of  the  process  is  not  to  push  the 
uterus  somewhere  for  the  feat  of  getting  it  within  reach  of  the 
hand,  nor  to  find  out  where  it  lies  by  forcing  it  into  a  situation 
where  it  did  not  lie  before  the  hand  disturbed  it.  What  is 
intended  is  the  manual  examination  of  the  body  of  the  uterus 
through  the  abdomen,  so  that  its  consistence,  its  bulk,  and  the 
regularity  of  its  surface  can  be  detected. 

The  left  hand  must  be  warm,  else  troublesome  contractions  of 
the  abdominal  muscles  and  much  discomfort  to  the  patient  will 
be  occasioned.  The  surgeon  must  see  that  no  clothes  get  in  the 
way  of  this  hand,  and  must  also  take  care  that  the  patient  does 
not  keep  her  hands  so  placed  as  to  be  able  to  seize  his  left  wrist 
suddenly  and  unexpectedly,  as  timid  subjects  are  wont  to  do. 
All  the  inconveniences  to  which  I  have  referred  must  be  borne 
in  mind,  for  bimanual  examination  is  worthless  unless  and  until 
the  surgeon  can  conduct  it  without  let  or  hindrance.  The  palm 
of  the  left  hand  should  be  gently  placed  on  the  epigastrium, 
and  passed,  with  steadily  increasing  pressure,  over  the  hypo- 
chondi'ia,  the  lumbar  and  umbilical  regions,  and,  lastly,  the 
hypogastrimn.  In  this  way  some  unsuspected  morbid  condition 
above  the  pelvis  may  be  detected.  The  bulbs  of  the  finger-ends, 
and  not  the  nails,  are  pressed  gently,  firmly,  and  steadily 
against  the  hypogastrium,  so  that  the  abdominal  walls  are 
depressed.     Hart   and   Barbour   rightly   recommend  that   the 


BIMANUAL    EXAMINATION. 


55 


inner  edge  of  the  hand  should  be  brought  to  bear  against 
the  abdomen,  for  pressure  with  the  whole  palm  may  retrovert 
the  uterus. 


Pig.  lo. — Bimanual  Examination. 

In  this  sketch,  only  one  finger  of  tlie  riglit  hand  has  been  introduced,  and  it 
is  being  pressed  against  the  anterior  vaginal  wall,  so  that  the  body  of  the 
uterns  may  be  felt  between  it  and  the  left  hand,  which  presses  on  the  hypo- 
gastrium.     {Sims. ) 

The  right  and  left  hands  being  thus  placed,  the  fingers  of 
each  are  pressed  towards  each  other.  The  surgeon  must  note 
what  can  then  be  felt  between  them.  The  fundus  uteri  is 
characteristic,  and  not  difficult  to  recognize,  except  in  a  stout 
patient.  It  is  easiest  to  explore  in  cases  of  subinvolution — that 
is  to  say,  in  patients  who  come  for  relief  from  bearing-down 
pains,  etc.,  shortly  after  recovery  from  confinement.  The  body 
of  the  uterus  will  feel  bulky,  and  the  beginner  may  believe  that 
it  is  abnormally  enlarged,  when  it  is  of  its  natural  dimensions 
under  the  circumstances.  The  surgeon  tests  the  mobility  of  the 
body  of  the  uterus,  and  may  be  able  to  detect  great  irregularities 
on  its  surface,  denoting  fibroid  growths;  or  he  may  find  a 
tumour  or  an  ill-defined  sohd  deposit  before  or  behind  it.  He 
then  explores  the  posterior  fornix  of  the  vagina  with  the  two 
fingers  of  the  right  hand,  pressing  over  the  uterus  with  the  left 
hand.  No  solid  body  is  to  be  detected  in  this  way,  if  the  parts 
be  free  from  disease. 

Lastly,  the  uterine  appendages  are  examined  in  the  same 


56  METHODS  OF  PELVIC  EXPLORATION. 

manner,  the  right  fingers  being  pressed  against  the  vault  of 
the  vagina  to  the  right  of  the  cervix  uteri,  and  the  left  against 
the  abdominal  walls  in  the  right  iliac  fossa.  Both  hands  must 
press  somewhat  backwards,  else  the  fingers  may  be  made  to  meet 
with  little  but  the  abdominal  parietes  and  the  A'aginal  walls 
]between  them,  passing  in  front  of  the  appendages  altogether, 
and  possibly  missing  a  morbid  deposit.  I  believe,  however, 
that  the  beginner  may  advantageously  commence  a  bimanual 
palpation  by  pressing  the  abdominal  and  vaginal  walls  together 
in  this  way,  continuing  the  pressure  afterwards  in  a  more  back- 
ward direction.  The  left  appendages  are  explored  in  the  same 
way.  In  health,  they  cannot  be  distinctly  made  out  on  either 
side.  Enlarged  and  tender  ovaries  are  not  difficult  to  discover, 
and,  with  a  little  experience,  even  the  com-se  of  a  dilated  tube 
may  be  traced  by  the  fingers.  Solid  deposits,  the  result  of 
pelvic  inflammations,  are  readily  detected.  I  must  observe, 
however,  that  in  chronic  cases  of  such  inflammations  even  the 
most  experienced  may  fail  to  detect  the  precise  extent  of  disease 
by  bimanual  examination. 

Once  more,  I  must  insist  upon  declaring  that  bimanual 
examination  must  be  learnt  by  those  who  undertake  to  cure 
the  diseases  of  women.  The  surgeon  must  teach  himself  what 
can  be  discovered,  and  must  be  aware  of  what  cannot  be 
detected,  by  this  invaluable  aid  to  diagnosis.  He  must  always 
learn  to  explore  by  two  fingers  of  the  right  hand  in  this  method 
of  examination.  The  forefinger  alone  should  only  be  used 
when  the  vagina  is  very  narrow. 

Bimanual  examination  should  entirely  replace  the  use  of  the 
sound  in  cases  where  pregnancy  may  exist,  and  where  there  is 
evidence  of  acute  or  subacute  pelvic  inflammation  or  malignant 
disease.  Emmet  and  others  reject  the  sound  altogether,  in  its 
favour,  in  all  cases  of  diseases  of  women.  Bimanual  examina- 
tion must,  however,  be  very  gently  and  carefully  conducted  in 
acute  inflammatory  disease,  and  always  preceded  by  vaginal 
exploration.  If,  during  such  exploration,  great  heat  of  the 
vagina,  solid  but  ill-circumscribed  deposit,  or  evidence  of  im- 
paired mobility  of  the  cervix  be  ascertained,  no  further  kind 
of  manual  examination  is  advisable  for  the  time.  In  cases 
of  cancer   of  the   cervix,  the  uterus  may  be   gently  explored 


THE    GENUPECTORAL    AND    SEMI-PRONE    POSITIONS.  57 

bimanually,  but  no  attempt  must  be  made  to  test  its  mobility. 
I  have  seen  such  an  attempt  set  up  haemorrhage  as  severe  as 
when  the  forefinger  is  roughly  thrust  into  the  canal  of  the 
diseased  cervix,  and  dangerous  pelvic  inflammation  may  follow. 

The  hands  must  be  thoroughly  washed  after  vaginal  explora- 
tion or  bimanual  examination,  and  the  nails  carefully  cleaned. 
Carbolic  and  "Sanitas"  soap  are  both  good  for  the  purpose. 
Foulis,  Hart,  and  Barbour  recommend  the  addition  of  a  few 
drops  of  turpentine.  This  aids  in  dispelhng  the  offensive 
odour  which  sometimes  clings  to  the  fingers,  as  well  as  acting 
antiseptically.  A  final  washing  in  water  containing  a  little 
glycerine,  and  thorough  drying  of  the  hands,  will  guard 
against  chaps,  a  soui'ce  of  actual  danger,  or,  at  the  least,  very 
disagreeable,  especially  if  many  patients  have  to  be  examined 
when  cold  weather  prevails. 

The  Genupectoral  and  Semi-prone  Positions. — These 
positions  allow  of  the  inspection  of  the  vagina  and  cervix.  If 
the  patient  be  placed  on  her  knees,  with  the  nates  elevated,  the 
chest  and  face  downwards  resting  on  the  couch,  and  the  face 
tm'ned  to  one  side,  atmospheric  pressure  will  separate  the 
vaginal  walls  when  the  surgeon  opens  the  vulvar  aperture. 
When  the  posterior  wall  is  elevated  by  the  forefinger  a  good 
view  can  be  obtained  of  the  vagina,  and  often  of  the  cervix  also. 
The  physical  mechanism  of  this,  the  genupectoral  podure,  has 
been  well  described  by  Drs.  Hart  and  Barbour. 

The  same  physical  conditions,  whereby  the  vagina  no  longer 
remains  a  closed  canal,  can  be  produced  by  placing  the  patient 
in  a  less  objectionable  posture,  the  semi-prone  position,  which 
often  bears  the  name  of  Marion  Sims.  The  patient  is  placed 
on  her  left  side,  with  the  knees  drawn  up ;  the  right  must  be 
the  more  flexed,  not  resting  on  the  left,  but  on  the  couch  itself. 
The  left  arm  is  drawn  gently  backwards  and  allowed  to  rest  as 
comfortably  as  possible  on  that  side  of  the  couch  towards  which 
the  patient's  back  is  turned.  The  patient  must  turn  her  chest 
and  face  downwards  towards  the  left  side  of  the  couch.  Care 
must  be  taken  that  the  chest  does  not  lie  flat  against  the  couch. 
The  aim  of  placing  the  patient  in  this  position  is  to  keep  the 
anterior  part  of  the  abdominal  walls  unsupported,  so  that  they 
slide  forwards  and  cause  the  vaginal  walls  to  part  when  the 


58  METHODS  OF  TELVIC  EXPLORATION. 

"sailva  is  opened  by  the  finger.  The  nates  should  lie  well 
towards  the  right  side  of  the  couch ;  the  right  or  uftpermost 
side  of  the  pelvis  must  he  rotated  a  little  forwards  towards  the 
left  of  the  couch. 

Provided  that  there  be  plenty  of  light,  this  is  an  excellent 
jDosition  for  examining  the  vagina.  The  cervix  may  be 
thoroughly  inspected  by  drawing  it  down  with  a  volsella. 
The  skirts  are  simph'-  raised  above  the  nates,  and  a  covering 
is  passed  over  the  lower  extremities,  so  that  the  region  of  the 
vulva  alone  need  be  uncovered.  When  the  patient  is  in  bed 
this  position  is  particularly  convenient. 

The  Speculum. — This  instrument  must  be  used  intelli- 
gently, and  the  surgeon  must  not  conclude  that  everything 
which  it  displays  is  in  a  morbid  condition.  Its  uses  are  limited ; 
still  it  is  indispensable.  A  very  large  assortment  of  specula  of 
all  shapes  and  sizes  may  be  seen  at  any  instrument-maker's 
shop.  Three  chief  varieties,  based  upon  different  principles, 
may  be  made  to  include  all  the  specula  in  common  use. 

The  first  variety  is  the  cylindrical  speculum,  made  to  be 
directed  straight  to  the  cervix,  which  it  brings  into  view.  This 
is  the  Fergusson  t}^e. 

The  second  variety  is  the  speculum  which  effects  its  objects 
by  the  assistance  of  the  physical  conditions  associated,  as  has 
akeady  been  described,  with  the  semi-prone  position  of  the 
patient.      This  is  the  Sims  type. 

The  third  variety  includes  all  specula  which  essentially  work 
by  any  kind  of  valvular  mechanism,  as  in  Neugebauer's  and 
Cusco's  instruments. 

Fergusson's  Speculum. — This  is  the  most  widely  used; 
in  some  respects  the  most  serviceable,  and  in  others  the  least 


FERGUSSON'.S   Sl'ECl'LUM. 


convenient,  of  all  specula  (Fig.  14).     It  is  a  hollow  cylinder 
of  stout  glass,  silvered  like  a  mirror,  and  coated  with  black 


fp:rgusson's  speculum.  59 

rubber*  Thi-ee  or  four  different  sizes  are  constructed.  Its 
orifice  is  everted ;  its  extremity  bevelled.  The  surgeon  should 
always  pass  his  finger  over  the  edges  of  this  extremity  before 
use,  as  it  is  apt  to  get  chipped,  so  as  to  cut  or  scratch  the  soft 
parts  when  the  speculum  is  carelessly  introduced.  Though 
said  to  be  self-retaining,  Fergusson's  speculum  can  never  be 
trusted  to  remain  in  place  without  support  from  a  hand  or 
finger.  Too  much  stress  is  laid  on  this  "  self -retaining " 
quality,  which  really  means  the  quality  of  not  slipping  out 
quite  so  readily  as  other  specula.  In  hospitals,  and  wherever 
help  is  at  hand,  there  is  no  necessity  for  employing  a  "self- 
retaining  "  speculum,  even  if  that  term  were  deserved  by  the 
instrument. 

Fergusson's  speculum  is  not  difiicult  to  introduce,  and  is  very 
handy  for  inspection  of  the  os  externum  and  adjacent  part  of 
the  cervix.  Straight  probes,  used  for  the  application  of  medi- 
cated preparations  to  the  cervix  and  endometrium,  can  be 
readily  employed  with  the  aid  of  this  speculum,  which  is  also 
valuable  in  emergencies,  when  the  vagina  requires  plugging 
for  hsemorrhage.  On  the  other  hand,  Fergusson's  speculum 
is  unfitted  for  cases  where  the  whole  of  the  vagina  and  the 
sides  of  the  cervix  have  to  be  explored.  The  narrow  calibre 
and  the  straight  cylindrical  walls  of  the  instrument  interfere 
with  the  handhng  of  the  sound,  volsella,  or  any  other  long- 
shanked  instrument. 

This  speculum  can  be  readily  introduced  when  the  patient 
has  been  placed  on  her  left  side,  as  during  digital  exploration 
of  the  vagina.  When  cancer  of  the  cervix  is  suspected,  and 
in  some  syphihtic  cases,  the  speculum  may  precede  or  entirely 
replace  digital  research.  It  must  be  warmed,  and  greased 
externally  with  carbolized  oil  or  vaseline.  The  vulva  is  then 
parted  by  the  fingers,  and  the  speculum  is  introduced  with  the 
longer  side  of  the  bevelled  end  backwards.  It  is  slipped 
upwards  till  the  cervix  comes  into  view.  As  it  passes  upwards 
it  should  be  gently  pressed  against  the  perineum  and  posterior 
vaginal  wall,  so  as  to  avoid  damage  to  anterior  structures.  The 
name  of  the  maker  is  generally  stamped  on  the  outside  of  the 

*  This  silvered  glass  answers  better  than  white  porcelain  or  briglit  nretal, 
and  resists  the  action  of  chemicals. 


60 


METHODS    OF    PELVIC    EXPLOKATIOX. 


everted  orifice  of  the  speculum,  at  a  point  in  a  line  "wdth  the 
shorter  side  of  the  bevelled  extremity.  When  the  speculum 
is  rightly  fixed,  the  name  lies  towards  the  pubes,  not  towards 
the  thighs  or  the  anus.  By  a  little  manipulation,  only  to  be 
learnt  by  practice,  the  cervix  can  be  placed  in  a  convenient 
position  for  inspection.  The  speculum  must  never  be  screwed 
round  and  round,  especially  when  it  touches  the  cervix ;  its 
extremity  should  simply  be  worked  into  the  posterior  fornix 
of  the  vagina.  A  volsella  is  more  useful  than  a  sound  for 
bringing  the  cervix  into  view  when  manipulations  are  in- 
sufficient. 

Fergusson's  speculum  can  also  be  passed  when  the  patient 
lies  in  the  lithotomy  position.  In  whatever  posture  she  has 
been  placed,  a  little  cleaning  will  be  necessary  when  the  cervix 


Fig.  15. — Speculum-Foeceps. 


.Speculi'm-Forcep.-- 


has  been  brought  into  sight.  This  is  managed  by  pledgets  of 
wool  held  by  the  speculum -forceps  (Figs.  15,  10)  and  brushed 
against  the  os.  There  is  generally  some  glairy  fluid  to  remove, 
but  often  the  secretion  is  curdy,  muco-purulent,  or  sanguineous. 
To  clean  the  cervical  canal,  some  wool  may  be  neatly  wrapped 


PLAYFAIr's    probe — PLUGGING    THG    VAGINA.  61 

around  the  end  of  a  Playfair's  probe  (Fig.  17),  which  is  some- 
times roughened  at  the  point  so  as  to  hold  the  wool.*  The  end 
of  the  probe  is  passed  up  the  canal,  gently  rotated,  and  then 


Fig.  17. — Playfair's  Probe. 

removed  ;  much  glair j  mucus,  at  least,  is  thus  withdrawn.  Both 
the  speculum  forceps  and  the  probe  should  always  be  used 
before  any  caustic  or  other  medicament  is  appHed  to  the  cervix 
or  to  its  canal. 

Plugging  the  Vagina. — Fergusson's  speculum  is  certainly 
useful  for  the  appHcation  of  plugs  to  the  vagina,  especially 
when  the  surgeon  is  suddenly  called  upon  to  check  uterine 
haemorrhage,  and  believes  that  this  may  be  effected,  at  least 
temporarily,  if  not  permanently,  by  means  of  vaginal  plugging 
alone.  The  speculum  is  first  introduced  so  as  to  bring  the 
cervix  and  os  well  into  sight.  Probably  a  tent  will  be  required 
for  the  cervical  canal,  and  instruments  have  been  devised  for 
its  introduction  ;  but  I  am  speaking  now  of  cases  of  emergency 
where  only  the  familiar  speculum  may  be  at  hand.  A  piece  of 
lint,  folded  several  times,  with  several  inches  of  stout  pack- 
thread or  twine  attached  to  it,  is  passed  up  the  speculum  and 
well  pressed  over  the  os,  and  tucked  into  the  vaginal  vault 
around  the  cervix.  Pledgets  of  absorbent  wool  or  tenax  are 
now  passed  up  the  speculum  by  means  of  speculum  forceps, 
and  pressed  against  the  lint ;  the  string  is  held  gently,  and  as 
the  pledgets  are  passed  the  speculum  is  gradually  retracted, 
so  that  each  pledget  is  packed  into  the  vagina,  and  not 
left  in  the  canal  of  the  speculum.  In  this  way  the  vagina 
may  readily  be  packed.  Too  great  traction  on  the  string 
must  be  avoided,  especially  at  first,  or  else  the  plug  of  lint 
will  be  displaced,  and  in  consequence  there  mU  be  least 
pressure  where  there  should  be  most.  This  precaution  being 
taken,  the  haemorrhage  will  be  checked,  and  the  plugs  will 
not  come  away  when  the  speculimi   is  withdrawn.     The   lint 

*  Some  writers,  such  as  Galabin,  object  to  notches  and  to  bulbous  extremities 
in  probes  of  this  kind.  They  prevent  tlie  ready  removal  of  the  wool.  Simple 
roughening  is  quite  sufficient. 


62 


METHODS    OF    PELVIC    EXPLORATION. 


should  be  steeped,  if  possible,  in  glycerine  of  tannic  acid. 
The  plug  should  not  be  left  in  longer  than  twenty-four 
hours.  To  remove  it,  the  wool  is  taken  away  piece  by  piece 
with  the  aid  of  speculum  forceps,  the  string  being  held  firmly. 
The  last  pledgets  ^all  come  away  with  the  hnt  on  pulling 
gently  at  the  string,  the  vagina  being  afterwards  well  washed 
with  an  antiseptic  solution.  Sometimes  a  piece  of  rag,  and 
long  strips  of  the  same  material,  are  alone  available  for  plug- 
ging. I  have  been  speaking  of  emergencies  alone.  More 
complicated  methods  of  plugging  for  the  arrest  of  htemor- 
rhage  are  in  vogue  amongst  speciahsts. 

Sims'  Speculum. — This  instrument  is  devised  so  that  the 
vagina  and  cervix  may  be  explored  by  its  aid,  assisted  by 
the  physical  conditions  of  the  semi-prone  postui'e  (page  57).  If 
the  principle  of  this  postui^e  be  understood,  there  will  be  Httle 
difficulty  and  great  advantage  in  the  use  of  Sims'  speculum. 


Fig.  18.— Sims'  Spfxitli:m. 


Sims'  speculimi  (Fig.  18)  is  a  solid  piece  of  metal,  bent 
at  right  angles  on  itself  at  each  end.  The  bent  portions  are 
about  four  inches  long,  and  concave  on  one  side,  each  form- 
ing a  speculum  blade,  one  stouter  and  wider  than  the  other. 
A  very  large  number  of  modifications  of  this  instrument  have 
been  devised.  In  some  the  blades  are  bent  back,  so  as  to 
form  acute  angles  with  the  connecting  bar  or  handle.  Some- 
times, as  in  Bozeman's  modification,  this  arrangement  exists, 
and  the  entire  instrument  is  also  made  heavier  than  in  the 
original  form.      Increased  weight  is  of   advantage  when  the 


SIMS'    SPECULUM.  63 

speculum  is  emploj^ecl  to  depress  the  perineum  whilst  ope- 
rations are  being  performed  when  the  patient  lies  in  the 
supine  position,  as  in  vesico-vaginal  fistula.  The  chief  modi- 
fications, however,  aim  at  making  Sims'  speculum  an  instru- 
ment which  can  be  used  without  the  aid  of  an  assistant,  even 
when  the  patient  is  placed  on  her  back.  This,  however,  is 
hardly  possible.  I  must  admit,  however,  the  value  of  that 
modification  of  Sims'  speculum  which  bears  a  metal  bar  bent 
so  as  to  form  a  kind  of  loop.  The  bar  acts  like  a  lever,  and 
pushes  upwards  the  anterior  vaginal  wall  when  its  extremity 
is  pressed  against  the  handle  by  the  thumb  of  the  same 
hand  which  holds  the  instrument.  This  variety  may  prove 
useful  when  no  assistance  is  at  hand,  and  it  is  very  suitable 
when  the  patient  is  placed  in  the  lithotomy  position.  Never- 
theless, Sims'  speculum  is  essentially  intended  for  use  in 
hospitals  and  in  places  where  skilled  assistance  is  at  hand. 

Before  Sims'  speculum  is  employed,  the  patient,  who  should 
lie  on  a  high  couch  or  operating-table  in  a  good  light,  must  be 
carefully  placed  in  the  semi-prone  position,  as  described  at 
page  57.  Unless  she  lies  accurately  in  that  position,  the 
speculum  cannot  be  used  properly,  for  the  vaginal  walls  will 
not  fall  apart,  as  they  are  intended  to  do. 

The  semi-prone  position  being  assumed,  that  blade  of  the 
Sims'  speculum  which  is  most  adapted  to  the  dimensions  of 
the  patient's  vagina  is  introduced  after  it  has  been  warmed 
and  greased.  The  bar  between  the  blades,  and  the  blade  which 
is  not  to  be  introduced,  are  grasped  in  the  left  hand,  the  thimib 
pressing  firmly  against  the  bar.  The  labia  are  parted  by  the 
introduction  of  two  fingers  into  the  vagina,  which  should  dilate 
of  itself  directly  they  enter ;  if  it  does  not  dilate,  the  patient 
is  not  lying  exactly  in  the  semi-prone  position.  Then  the 
blade  is  passed  sideways  into  the  vulvar  cleft,  rotated  back- 
wards as  it  enters  the  vagina,  and  slipped  along  the  posterior 
wall  till  it  reaches  the  posterior  vaginal  fornix.  By  di^awing 
the  instrument  backwards  and  tilting  its  point  forwards,  keep- 
ing up  a  little  gentle  pressure  on  the  perineum,  the  cervix  and 
OS  will  come  in  sight.  The  cervix  may,  if  necessary,  be  drawn 
down  with  the  volsella.  A  depressor  is  hardly  needed  when 
the  patient  is  accurately  placed.     The  uterine  sound  and  other 


64  METHODS    OF    PELVIC    EXPLORATION. 

long-handled  instruments  can  readily  be  used  while  this  spe- 
culimi  lies  in  the  vagina. 

For  vesico-vaginal  fistula,  trachelorraphy,  operations  for  the 
removal  of  vascular  urethral  growths,  etc.,  this  speculum  is 
used  with  the  patient  lying  on  her  hack.  It  is  grasped  in 
the  same  manner,  and  one  blade  is  slipped  along  the  posterior 
vaginal  wall,  the  labia  being  parted  with  the  fingers.  The 
cervix  may  be  tilted  into  a  convenient  position  by  the  beak 
of  the  blade ;  an  assistant  then  presses  the  blade  gently  but 
firmly  against  the  perineum,  and  holds  it  in  that  position 
dm-ing  the  operation.  When  so  engaged,  the  connecting  bar 
should  be  grasped  by  one  hand,  right  or  left  as  best  suits  his 
position  in  respect  to  the  operator,  the  thumb  being  pressed  into 
the  extremity  of  the  concavity  of  the  blade  which  is  in  use. 
The  assistant's  hand  may,  however,  be  in  the  way ;  if  so,  he 
must  grasp  the  lower  blade,  the  thumb  lying  in  its  concavity 
close  to  the  connecting  bar.  These  directions  will  not  be  dif- 
ficult to  understand  if  the  surgeon  takes  a  Sims'  speculum  in 
his  hand  as  he  reads  them.  "With  regard  to  the  concavity  of 
each  blade  prolonged  over  the  angle  on  to  the  connecting-bar, 
it  serves  several  purposes.  Thus,  as  just  described,  it  acts  as 
a  thumb-rest.  It  also  allows  depression  of  the  handle  of  any 
instrument  used  during  examination,  and  facilitates  the  escape 
of  fluids  or  coagula. 

Valvular  Specula. — Some  specula  have  a  valvular  action 
complete  in  themselves,  the  Sims  type  acting  only  as  part 
of  a  valve. 

The  valvular  specula  include  two  varieties.  In  the  first, 
the  instrument  consists  of  two  separate  pieces,  which  slide 
upon  each  other  after  introduction,  and  thus  form  a  valve. 
Neugebauer's  and  Barnes'  specula  are  of  this  type.  In  the 
second,  the  instrument  is  made  in  one  piece,  consisting  of 
two  valves,  which  open  by  a  special  mechanism.  This  is  the 
case  in  Cusco's  speculum. 

Neugebauer's  Speculum. — This  instrument  (Fig.  19) 
consists  of  two  deeply-hollowed  pieces  of  metal,  everted  at 
the  extremity  to  be  introduced  into  the  vagina,  and  furnished 
with  a  short,  straight  handle.  A  graduated  set  of  blades 
must    be  kept  in    hand,  and   the   speculum   consists,  as  just 


NEUGEBAEEr's    speculum BARNEs'    SPECULUM.  65 

observed,  of  two  such,  blades,  one  able  to  slide  in  the  other. 
The  broader  blade  is  warmed,  greased  on  its  convex  aspect, 
and  passed  along  the  posterior  vaginal  wall.  The  patient  may 
lie  either  on  her  side  or  on  her  back.  The  everted  extremity 
of  the  blade  must  be  made  to  push  back  the  posterior  vaginal 
fornix,  against  which  it  rests.  Then  the  narrower  blade  is 
warmed  and  greased  in  the  same  manner,  and  slipped  along 
the  anterior  vaginal  wall,  its  edges  sliding  within  those  of 
the  other  blade.      The  extremity  is  pushed   into  the  anterior 


Fig.  19. — Xeugebauer's  Speculum. 

fornix.  By  approximating  the  handles,  the  extremities  are 
parted,  so  that  they  press  against  the  vaginal  vault  in  opposite 
directions,  and  expose  the  cervix,  everting  its  canal  more  or 
less,  as  may  be  desired. 

Barnes'  Crescent  Speculum  (Fig.  20)  is  a  modifica- 
tion of  Neugebauer's.  "Finding,"  Dr.  Barnes  writes  in  his 
Clinical  History  of  the  Medical  and  Surgical  Diseases  of  Women, 
"  that  when  dealing  with  stout  patients  the  handles  of  Neuo-e- 
bauer's  instrument  were  too  short  to  be  easily  commanded,  I  have 
made  what  I  find  in  practice  a  very  convenient  modification. 

1  have  substituted  for  the  handle  another  blade.  Two  pieces 
make  a  series — three  different  sizes  of  speculum.  The  grada- 
tion is  effected  by  having  Nos.  1  and  3  in  one  piece,  and  Nos. 

2  and  4  in  the  other.     By  using  No.  1  with  No.  2  we  get  the 

F 


66 


METHODS    OF    PELVIC    EXPLORATION. 


largest  size ;  b}'  using  No.  2  "uitli  No.  3  we  get  the  next  size ; 
by  using  No.  3  with.  No.  4  we  get  the  smallest  size.  The  ends 
outside  the  vagina  form  excellent  handles."  Dr.  Barnes' 
instrument  is  very  portable. 

This  form  of  speculum  is  of  high  value.  It  is  particularly 
needed  when  the  cervix  requires  special  attention.  I  have 
found  Neugebauer's  sjoeculum  very  useful  for  the  application 
of  medicated  fluids  to  the  os  and  cervical  canal  when  the  patient 
lies  in  bed  on  the  left  side.  The  cervical  canal  is  readily 
widened  near  the  os  by  simply  approximating  the  handles. 
The  instrument  is  most  convenient  in  a  hospital  ward  or 
wherever  a  nm-se  or  assistant  is  present.     The  evei'ted   canal 


Fig.  20. — Barnes'  Crescent  Si-eculum. 


of  the  blade  allows  far  freer  movements  of  any  long-handled 
instrument  than  does  Fergusson's  speculum,  and  the  uterine 
sound  can  be  used  with  facility  without  disturbing  the  cervix. 
As  to  the  argument  that  this  speculum  requires  an  assistant,  I 
have  replied  to  it  in  the  case  of  Sims'  instmment. 

Cusco's,  or  the  Bivalve  Speculum. — There  are  a  very 
large  number  of  varieties  of  hinged,  bivalve  specula,  and  many 
works  on  diseases  of  women,  by  standard  authors,  are  adorned 
by  a  long  series  of  woodcuts  of  ingenious  contrivances  of  this 
kind,  bearing,  of  course,  the  names  of  the  inventors.  Multi- 
plicity of  varieties  of  an  instrument  generally  implies  either 
defects  difficult  to  avoid,  or  attempts  to  combine  qualities  which 
cannot  readily  be  combined.  The  defects,  in  the  case  of  many 
bivalve  specula,  are  a  want  of  that  self-retaining  property  which 


CUSCO'S,  OR  THE  BIVALVE  SPECULUM.  67 

has  been  claimed  for  them,  an  awkward  arrangement  of  the 
mechanism  which  works  the  valves,  and  the  absence  of  some 
contrivance  to  display  a  large  surface  of  the  vaginal  wall. 
To  combine  the  best  self-retaining  contrivance  with  the  best 
mechanism  for  opening  and  closing  the  valves  and  at  the  same 
time  to  ensure  a  good  view  of  the  vaginal  wall  when  the 
speculum  is  fixed,  the  instrument  remaining  workable  for  any 
person  a  little  versed  in  the  treatment  of  diseases  of  women,  is 
probably  an  impossible  task. 

Cusco's  (Fig.  21)  is  the  best  form  of  bivalve  s]3eculum.  There 
are  several  sub-varieties.  In  the  best  type  there  are  two  blades 
of  equal   length   broad,  fattened,  and  concave  internally.     A 


Fig.  21. — Cusco's  Bivalve  Speculum. 

thumb-piece  is  attached  to  one  blade,  and  a  screw  passes  through 
the  thumb-piece,  to  be  fixed  to  a  projection  from  the  other 
blade.  The  two  blades  are  connected  by  a  hinge,  and  can  be 
parted  by  pressure  on  the  thumb-piece  ;  a  metallic  button  fixes 
the  screw  at  any  desired  point,  so  as  to  regulate  the  gape  of  the 
blades.  Some  instruments  sold  under  the  name  of  Cusco  have 
a  different  mechanism  for  working  the  blades.  Others  have 
fenestrated  blades,  designed  to  allow  a  view  of  the  vagina,  but 
they  effect  their  purpose  very  imperfectly,  and  increase  the 
unfortunate  tendency  of  this  kind  of  speculum  to  hmi  the 
vaginal  walls.  Lastly,  some  "  Cusco's  "  have  blades  of  unequal 
length.  Those  who  hold  that  one  blade  should  act  as  a  mere 
repressor,  of  the  kind  often  employed  with  Sims'  instrument, 


68  METHODS  OF  PELVIC  EXPLORATION. 

prefer  that  one  blade  should  be  short.  Other  authorities,  such 
as  Galabin,  contend  that  both  should  be  of  equal  length,  so  that 
the  axis  of  the  uterus  may  be  brought  as  nearly  as  possible  into 
a  line  with  that  of  the  vagina.  Altogether,  the  latter  opinion 
coincides  the  most  with  the  utiKty  of  the  instrument. 

When  Cusco's  speculum  is  used,  the  outer  sides  of  the  blades 
are  warmed  and  oiled,  and  the  patient  being  placed  on  her  side 
or  back,  according  to  circumstances,  the  blades  are  passed  "«dth 
their  outer  surfaces  facing  the  corresponding  labia.  When 
well  introduced  the  instrument  is  rotated  so  that  the  outer 
surface  of  the  blade  bearing  the  thumb-piece  lies  against  the 
anterior  vaginal  wall.  On  working  the  screw  by  pressing  the 
thumb-piece,  the  other  blade  "\^dll  depress  the  posterior  wall,  and 
the  cervix  will  appear  at  the  end  of  the  parting  blades.  When 
the  cervix  is  well  in  view,  with  the  os  forwards  towards  the 
operator,  the  screw  may  be  fixed.  In  rotating  and  in  mth- 
drawing  the  blades  the  vagina  may  get  pinched,  especially  if 
they  are  carelessly  allowed  to  close  as  the  speculum  is  being 
moved.  There  is  also  some  danger  of  entangling  some  of  the 
pudendal  hairs  in  the  screw. 

Cusco's  speculum  is  an  ingenious  instrument,  very  portable 
and  easier  for  beginners  to  Avork  than  Sims',  but  not  nearly  so 
valuable  when  the  semi-prone  posture  is  understood.  It  does 
not  throw  so  good  a  light  upon  the  cervix  as  does  Fergusson's, 
but  is  more  convenient  for  the  application  of  medicated  pre- 
parations to  the  cervix  and  its  canal,  and  for  the  introduction 
of  the  sound.  It  cannot  be  well  used  without  an  assistant  to 
keep  a  finger  against  the  thumb-piece  whilst  the  sm-geon  is 
inspecting  or  oj^erating  on  the  cervix.  It  is  almost  as  useless 
as  Fergusson's  for  inspecting  the  vagina,  and  far  inferior  to 
Sims'  for  operations  on  the  vagina  or  cervix. 

Every  sm-geou  should  possess  a  set  of  Fergusson's  and  Sims' 
specula,  and  should  learn  how  to  use  them  as  directed.  He 
may  dispense  yviih  any  bivalvular  form,  or  at  least  keep  either 
Neugebauer's  or  Cusco's  instrument,  but  to  keep  both  would  be 
superfluous.  Fergusson's  can  be  put  to  its  limited  uses  almost 
anywhere.  Sims'  will  be  of  great  service  in  the  operating- 
room,  the  consulting-room,  or  wherever  skilled  assistance  and  a 
good   couch  are  at   hand.      A  bivalve  speculum  is  useful  for 


THE    SPECULUM RECTAL    EXAMINATION.  69 

applications  to  the  cervix  or  endometrium  when  the  patient  lies 
in  bed,  especially  in  a  private  house. 

Lastly,  Drs.  Hart  and  Barbour's  words  should  be  remembered 
by  all :  "  If  the  patient  be  placed  in  the  genupectoral  or  semi- 
prone  posture,  the  posterior  vaginal  wall  hooked  back  with  the 
fingers,  and  the  cervix  drawn  down  with  a  volsella,  a  useful 
view  can  be  obtained  without  the  aid  of  any  speculum."  This 
is  the  best  way  to  examine  the  vaginal  walls. 

The  speculum  is  not  a  dangerous  instrument  to  introduce  in 
suspected  pregnancy,  if  used  very  gently.  When  there  is  much 
probability  that  advanced  cancer  of  the  uterus  exists,  the  finger 
should  first  be  introduced  ;  and  if  the  vaginal  walls  or  recto- 
vaginal septum  be  involved,  it  is  best  not  to  pass  the  speculum, 
which  may  bruise  the  cancerous  tissues  and  cause  serious  htemor- 
rhage.  At  this  stage  local  applications  will  be  ahnost,  if  not 
entirely,  useless. 

For  the  inspection  of  lacerations  of  the  cervix,  Sims'  in- 
strument is  alone  thoroughly  reliable,  for  the  bivalve  specula 
will  part  a  fissure  to  such  an  extent  as  to  efi:ace  it,  making  it 
appear  as  a  wide  plane  surface,  and  Fergusson's  speculum  will, 
on  the  other  hand,  press  the  sides  of  the  fissure  together. 

Any  speculum  should  after  use  be  well  washed  in  a  strong 
solution  of  Condy's  fluid,  or  in  a  1-in-lO  solution  of  sulphurous 
acid  or  a  l-in-40  solution  of  phenol. 


Before  speaking  of  the  sound,  I  will  describe  the  different 
methods  of  exploring  the  pelvic  organs  through  the  rectum  and 
bladder.  These  methods  are,  to  a  certain  extent,  homologous 
to  simple  and  bimanual  exploration  through  the  vagina. 

Rectal  Examination. — This  method  of  examination  must 
be  conducted  proj)erly  and  on  special  principles,  like  any  other 
method.  It  does  not  signify  a  perfunctory  search  with  one 
finger  of  either  hand  introduced  anyhow  into  the  rectum. 
When  carried  out  on  scientific  principles,  it  may  prove  an  im- 
portant guide  to  ascertain  the  condition  of  the  internal  organs. 
The  sm^geon  must  not  forget  that  many  patients  object  strongly 


70  METHODS  OF  PELVIC  EXPLORATION. 

to  this  form  of  examination.  Vaginal  exploration  is  pro- 
bably expected  beforehand,  so  that  the  patient  is  prepared  for 
it,  but  the  introduction  of  the  finger  into  the  rectum,  if  unex- 
pected, may  cause  great  alarm.  The  dilatation  of  the  sphincter, 
however  genth*  performed,  generally  produces  pain — severe  if  a 
fissure  exist,  as  is  not  rare  in  women.  The  patient  is  also  apt 
to  think  that  the  surgeon  is  making  a  mistake  in  exploring 
the  rectmn.  Hence  a  little  explanation  on  his  part  is  advisable, 
for,  as  I  have  ah-eady  observed,  loss  of  confidence  is  a  great 
bar  to  a  fi'ee  examination  of  the  pehdc  organs,  unobstructed 
by  muscular  contractions  or  by  the  patient's  own  restlessness. 
Above  all,  the  surgeon  must  never  introduce  the  finger,  after 
employing  it  in  this  way,  into  the  vagina  without  first  wash- 
ing it. 

Introduction  of  the  Entire  Hand  into  the  Rectum. 
— This  process,  introduced  by  Simon,  is  difiicult  and  danger- 
ous. It  is  wrong  to  speak  triumphantly  about  being  able 
to  reach  the  kidney,  without  noting  that  the  peritoneum  is 
frecjuently  torn  in  the  attempt,  and  that  the  sphincter  may  be 
irremediably  damaged.  Dr.  Thorburn  has  rightly  observed 
that  we  must  not  let  enthusiasm  for  diagnosis  endanger  a 
patient ;  and  Dr.  Gaillard  Thomas  maintains  that,  "  except 
in  a  very  few  rare  cases,  it  should  be  expunged  from  the  list 
of  exploratory  measures  in  gynaecology."  Even  the  above 
qualification  may  be  rejected. 

Simple  Rectal  Examination  is  often  required  as  a  sub- 
stitute for  vaginal  exploration  in  virgins,  and  for  bimanual  ex- 
ploration in  bad  cases  of  pelvic  inflammation.  It  is  also  neces- 
sary in  thorough  exploration  of  the  appendages ;  in  which  case 
the  patient  should  be  put  under  the  influence  of  an  anaesthetic. 
Before  rectal  examination  the  surgeon  should  rub  soap  well 
under  the  nail  of  the  right  forefinger  and  over  its  root.  The 
patient  can  be  most  conveniently  examined  if  placed  on  her 
back.  The  lateral  position  is  inconvenient,  especially  if  the  right 
forefinger  be  used,  as  it  obhges  the  sm-geon  to  stand  in  awk- 
ward positions  ;  nor  is  the  necessary  pronation  and  supination 
of  the  engaged  hand  easy  under  these  circumstances.  When 
the  patient  is  in  the  supine  position  the  wrist  can  be  moved 
with  ease  and  freedom. 


RECTAL    EXAMINATION.  71 

The  finger  first  overcomes  the  sphincter  ani  externus,  and 
then  it  passes  forwards.  It  enters  the  dilated  lower  third  of 
the  rectum,  generally  meeting  scybala.  Internal  haemorrhoids 
or  some  other  local  disease  may  also  be  detected.  On  feeling 
through  the  anterior  part  of  the  rectal  waU,  the  cervix  is  to  he 
distinguished.  The  whole  of  that  part  of  the  uterus  can  be 
felt, — not  only  the  vaginal  portion,  as  in  digital  exploration  of 
the  vagina.  Hence  the  cervix  feels  much  larger  in  rectal  exa- 
mination, and  it  must  not  be  taken  for  the  body  of  the  uterus, 
or  for  a  morbid  gro'^i;h.  When  the  uterus  is  retroflexed,  the 
fundus  can  be  felt  through  the  rectum,  above  the  cervix.  Hart 
and  Barbour  have  shown  that  a  uterus  anteflexed,  but  drawn 
backwards  by  cellulitis  of  the  utero-sacral  ligaments,  simulates 
retroflexion  when  the  vagina  is  explored,  whilst  on  rectal  exa- 
mination the  finger  can  detect  the  fundus  going  forward  above 
the  cervix. 

Thus  the  chief  advantage  of  rectal  examination  is  the  facility 
with  which  the  finger  can  be  slijDped  along  the  back  of  the 
entire  cervix  and  the  body  of  the  uterus,  an  impossibility  in 
vaginal  exploration,  as  the  finger  is  arrested  in  the  posterior 
fornix.  When  the  uterus  lies  high,  it  may  be  pulled  doTvn  by 
means  of  a  volsella.  Eectal  examination  is  also  of  great  value 
when  there  is  a  uterine  tumour  in  the  vagina,  of  uncertain 
natui'e,  too  bulky  to  allow  a  proper  exploration  of  tlie  cervix 
through  the  vagina.  This  can  readily  be  done  through  the 
rectum,  and  in  this  manner  a  fibroid  polypus  may  be  distin- 
guished from  an  inverted  uterus — a  diagnosis  often  particularly 
important  when  a  large  polypus  is  in  process  of  extraction 
piecemeal  through  the  vagina,  and  the  operator  knows  that  he 
has  been  keeping  up  prolonged  traction  on  the  uterus. 

The  appendages  can  also  be  explored  in  this  manner. 
Indeed,  it  is  only  through  the  rectum  that  the  back  of  the 
broad  ligaments  can  be  explored.  This  exploration  is  absolutely 
necessary  in  cases  of  cancer  of  the  uterus,  as  the  surgeon  is 
bound  to  ascertain  whether  the  disease  has  extended  to  the 
appendages.  It  is  also  required  in  cases  of  extra-uterine 
pregnancy,  hsematocele,  and  pelvic  inflammation. 

Recto-abdominal  Examination. — Bimanual  examination 
may  be  conducted  with  one  finger  in  the  rectum  and  the  opposite 


72  METHODS  OF  PELVIC  EXPLORATION. 

hand  on  the  abdomen,  as  in  the  more  usual  method,  but  the 
cervix  cannot  be  so  well  steadied  as  when  the  finger  is  in  the 
vagina.  When,  however,  rectal  examination  is  made  as  above 
directed,  it  is  always  advisable  to  conclude  by  making  the 
patient  lie  on  her  back  and  pressing  with  the  disengaged  hand 
on  the  hypogastrium, — that  is,  by  making  the  exploration 
bimanual.  This  recto-abdominal  examination,  as  it  has  been 
termed,  is  often  useful  in  the  case  of  virgins.  It  is  still  more 
valuable  in  cases  of  atresia  vaginae,  with  or  without  retention 
of  menses,  and  in  other  malformations  of  the  genitals,  as,  for 
instance,  when  absence  of  the  uterus  is  suspected. 

Recto-vaginal  Examination. — Dr.  Tilt's  double  touch, 
or  toucher,  by  introduction  of  the  thmnb  into  the  vagina  and 
the  forefinger  into  the  rectum,  is  chiefly  useful  when  the 
recto-vaginal  septum  requires  special  examination,  or  when  the 
surgeon  meets  with  some  apparent  discrepancies  as  the  result 
of  separate  exploration  through  the  vagina  and  through  the 
rectum.  Some  authorities  prefer  to  use  the  two  forefingers  for 
this  purpose. 

Ahdo)nino-recto-ra(jinal  Exaniiuatioii,  as  recommended  by 
Hart  and  Barbour,  is  performed  in  precisely  the  same  manner 
as  the  ordinary  bimanual  examination  described  at  page  53, 
excepting  that  the  right  forefinger  is  passed  into  the  vagina 
and  pressed  against  the  os,  and  the  right  middle  finger  is 
introduced  into  the  rectum.  This  method  may  prove  valuable 
in  the  exploration  of  cases  of  suspected  tubal  disease. 

Vesico-rectal  Examination. — Dilatation  of  the  ui-ethra 
for  the  purpose  of  introducing  a  finger  is  only  justifiable  in  some 
cases  of  suspected  disease  in  the  bladder  itself.  To  adopt  this 
method  for  the  exploration  of  the  uterus  and  its  appendages 
is  to  sacrifice  the  patient  to  diagnosis ;  in  fact,  it  is  open  to  the 
same  objection  which  applies  to  Simon's  manual  exploration  of 
the  rectum. 

In  cases  of  atresia  vaginae  and  suspected  absence  or  mal- 
formation of  the  uterus,  a  catheter  or  sound  may  be  passed 
into  the  bladder  and  held  firm  whilst  the  rectum  is  exjalored 
with  the  finger.  The  catheter  is  pressed  gently  backwards,  and 
then  the  finger  can  detect  the  presence  or  absence  of  the  uterus 
between  itself  and  the  catheter.     Even  when  the  vagina  exists. 


VESICO-RECTAL    EXAMINATIOIS THE    SOUND.  /  o 

it  is  better  to  explore  from  the  rectum,  as  the  site  of  the  body 
of  the  uterus  is  most  easily  reached  in  that  way.  Yesico-rectal 
examination  is  sometimes  of  use  in  very  fat  patients  where  the 
body  of  the  uterus  cannot  be  readily  explored  by  the  ordinary 
bimanual  method. 

The  Sound. — This  is  an  indispensable  instrument,  which, 
however,  must  be  emjDloyed  with  caution,  and  the  surgeon 
must  never  forget  that  its  passage  is  a  minor  surgical  operation. 
Authorities  are  much  divided  about  the  best  form  of  sound.  It 
must  not  be  too  long,  nor  deeply  notched  ;  sounds  made  to  fold 
in  two  by  means  of  a  hinge  are  objectionable,  as  are  sounds 
made  to  serve  other  purposes  besides  that  for  which  the  instru- 
ment in  question  is  designed. 

The  most  useful  form  of  sound  for  surgical  purposes  is  about 
nine  and  a  half  inches  in  length  (Fig.  22).     It  should  be  made 


Fig.  22. — Uterixe  Sound. 

of  silver  or  plated  copper,  and  must  be  thoroughly  flexible,  yet 
not  too  soft.  The  handle  should  be  about  an  inch  and  a  half 
long,  and  about  half  an  inch  broad  at  its  lower  or  wider  por- 
tion. When  the  handle  is  too  small,  it  is  not  so  convenient  for 
the  fingers,  unless  the  surgeon  be  very  experienced  in  the  use 
of  the  sound.  The  front  of  the  handle  should  be  well  rough- 
ened, and  its  back  need  not  be  covered  with  a  layer  of  wood. 
An  entirely  metallic  instrument  is  the  easiest  to  clean 
thoroughly  without  damage  to  itself. 

The  shank  should  be  about  six  inches  in  length,  and  equal  in 
calibre  to  a  No.  6  Enghsh  catheter.  At  its  upper  limit  it  forms 
an  obtuse  angle  with  what  may  be  termed  the  uterine  portion  of 
the  instriunent.  This  portion  must  be  two  and  a  half  inches 
long  and  slightly  curved.  Close  to  its  extremity  its  cahbre 
must  be  narrowed  so  that  the  end  of  the  sound  forms  a  bulb, 
of  the  calibre  of  the  greater  part  of  the  uterine  portion. 
There  should  be  a  small  notch  at  the  angle  formed  by  this 
portion  and  the  shank. 


74  METHODS    OF    PELVIC    EXPLORATION. 

The  Use  of  the  Sonnd. — The  manner  of  passing  the  sound 
is  only  to  be  properly  acquired  by  practice,  after  watching 
how  that  instrument  is  employed  by  those  who  are  experienced 
in  its  use.  There  is  little  difficulty,  in  these  days,  in  gaining 
the  requisite  instruction. 

The  instrument  may  be  passed  whilst  the  patient  is  lying 
on  her  back,  but  it  is  far  better  to  introduce  it  as  she  lies  on 
her  left  side,  with  her  knees  drawn  up  and  her  head  and 
shoulders  bent  down,  as  in  ordinary  digital  exploration  of  the 
vagina.  There  is  no  objection  to  changing  the  patient's  posi- 
tion while  the  sound  is  lying  in  the  uterus  ;  indeed,  this  is 
generally  necessary  in  the  course  of  diagnosis,  but  the  handle 
of  the  instrument  must  be  guarded  as  the  patient  moves,  else 
it  may  slip  out,  or  catch  in  the  clothing,  so  as  to  get  pushed 
upwards  with  some  violence. 

The  right  forefinger  is  placed  against  the  anterior  lip  of  the 
OS  externum.  The  handle  of  the  sound  is  taken  between  the 
left  finger  and  thumb,  the  point  having  been  warmed,  and 
greased  with  oil  or  vasehne.  The  point  is  then  guided  along 
the  right  forefinger  to  the  os ;  this  can  best  be  done  with  the 
convexity  of  the  curved  extremity  of  the  sound  forwards.  The 
point  is  now  introduced  into  the  os — an  easy  manoeu^^*e  unless 
that  orifice  is  extremely  narrow.  When  it  is  lacerated  there 
will  be  some  difficulty  in  getting  the  point  of  the  sound  into 
the  cervical  canal.  Should  the  fundus  be  evidently  retroflexed, 
the  handle  of  the  sound  must  be  swung  towards  the  pubes  ;  then 
with  a  little  gentle  pressure  the  point  will  slide  into  the  uterine 
cavity.  If  there  be  no  retroflexion,  the  point  of  the  sound  is 
pressed  upwards  till  it  comes  to  a  check,  in  the  cervical  canal, 
generally  at  the  os  internum.  Then  the  handle  is  swung  from 
behind  forwards,  describing  a  semicircle  in  the  direction  of  the 
right  or  uppermost  side  of  the  patient.  The  concavity  of  the 
curved  end  of  the  sound  will  now  lie  forwards,  and  with  gentle 
pressure  the  point  vnll  shp  into  the  uterine  cavity. 

When  there  is  evidence  of  extreme  retroflexion,  the  point  of 
the  sound  should  be  bent,  so  as  to  make  its  curve  stronger  than 
usual.  When  the  fundus  is  much  anteflexed  or  pushed  down 
by  a  tumour,  the  sound  should  be  bent  in  the  same  manner,  and 
introduced  into  the  os  with  the  concavity  of  the  curve  forwards. 


THE    SOUND.  75 

In  this  ease,  it  is  best  to  hold  the  sound  in  the  right  hand ; 
the  patient  must  then  lie  almost  horizontally. 

Two  precautions  must  be  observed  during  the  act  of  intro- 
ducing the  sound.  The  cervix  must  never  be  pressed  forcibly  by 
the  right  forefinger  in  the  direction  of  the  point  of  the  sound ; 
the  finger  is  simply  a  guide  to  the  os.  The  sound  must  be  siviing 
round,  when  necessary,  in  the  manner  just  described,  and  never 
hcirled  round — that  is,  rotated  on  its  long  axis.  This  rule  must 
also  be  observed  in  reducing  a  retroflexion  after  introduction  of 
the  sound.  Twiiiing  the  handle  may  succeed  in  forcing  the 
sound  into  the  aterine  cavity,  but  it  is  liable  to  cause  the  point 
to  scratch  the  endometrium,  and  is  otherwise  objectionable. 

Two  conditions  are  especially  to  be  sought  by  the  aid  of  the 
sound :  these  are,  the  length  of  the  uterine  cavity,  and  the 
mobility  of  the  uterus  in  relation  to  a  suspected  tumour. 

Length  of  the  Uterine  Cavity. — The  surgeon  can  always  detect 
an  elongation  of  that  cavity  by  the  manner  in  which  the  sound 
can  be  j)assed  far  upwards,  but  he  must  be  precise  and  never 
neglect  the  rule  of  taking  the  measurement.  This  is  done  by 
pressing  the  right  forefinger  against  the  sound  at  the  point 
where  that  instrument  enters  the  os  externum.  Then  the  sound 
is  removed,  the  finger  being  kept  against  the  point  just  men- 
tioned. The  distance  from  the  finger  to  the  point  of  the  sound 
will  represent  the  length  of  the  cavity  of  the  uterus  and  the 
cervical  canal.  This  manoeuvre  must  be  observed,  as  routine 
practice,  at  the  end  of  every  examination  with  the  sound,  and 
the  measurements  accurately  recorded.  The  direction  of  the 
cavity  must  be  noted.  Subinvolution  and  various  forms  of 
fibroid  disease  of  the  uterus  are  especially  denoted  by  increased 
length  of  the  uterine  cavity. 

The  sound  may  perforate  the  uterine  walls,  or  may  pass 
along  a  patent  Fallopian  tube.  Strange  to  say,  accidents  of 
this  kind  do  not  seem  to  cause  grave  symptoms.  I  have 
spoken  of  j)atent  Fallopian  tube  at  page  24. 

Mohilit;/  of  the  Uterus  in  relation  to  a  Suspected  Tumour. — 
The  surgeon  shoidd  prefer  bimanual  palpation  for  the  pur- 
pose of  ascertaining  whether  the  uterus  be  movable  or  fixed. 
There  will  then  be  less  risk  of  injury  than  when  the  sound,  a 
powerful  lever,  is  employed.     On  the  other  hand,  the  soimd  is 


76  METHODS  OF  rELVIC  EXPLORATION. 

absolutely  necessary  when  a  tumom^  exists,  and  the  surgeon 
wishes  to  ascertain  whether  it  moves  with  or  is  free  from  the 
uterus.  The  sound  being  introduced  into  the  uterus,  the 
sui-geon  lays  his  hand  on  the  abdomen  and  moves  the  tumour  in 
all  possible  directions  ;  then  he  has  the  opportunity  of  finding 
out  if  the  uterus  move  as  well.  The  sound  may  also  be  very 
gently  rotated,  laterally  and  backwards  and  forwards,  so  that 
the  amount  of  independent  mobility  of  the  uterus  can  be  de- 
tected. It  is  self-evident  that,  in  cases  of  abdomino-pelvic 
tumour,  bimanual  palpation  can  but  imperfectly  be  carried  out. 

The  relations  of  polypi,  and  the  diagnosis  between  pedun- 
culated polypus  and  inverted  uterus,  require  the  aid  of  the 
sound  for  their  accurate  determination. 

FrecantioiiH  in  ming  the  Sound— 1  have  abeady  noted  the 
danger  of  testing  the  amount  of  mobility  of  the  uterus.  Should 
there  be  evidence,  through  symptoms  and  digital  or  bimanual 
examination,  of  either  pelvic  cellulitis  or  perimetritis,  the  in- 
strument should  not  be  used,  or  at  the  most  only  passed  in  for 
measm^ement  of  the  uterine  cavity.  When  the  soimd  is  turned, 
it  must  not  be  rotated  on  its  long  axis — that  is,  simply  twisted 
round  like  a  screw;  the  handle  must  be  rotated  from  before 
backwards,  or  in  the  opposite  direction,  sweeping  round  by 
the  right  thigh  when  the  patient  is  lying  on  her  left  side.  The 
point  of  the  sound  must  be  slipped  gently  along  the  uterine 
cavity,  as  a  wound  of  the  endometrium  may  cause  serious 
pelvic  inflammation. 

To  avoid  the  risk  of  abortion,  the  patient  must  be  asked,  before 
the  sound  is  introduced,  the  date  of  her  last  period,  and  the 
uterus  must  also  be  carefully  explored.  The  sm-geon  must 
never  forget  that  a  single  patient  may  make  mendacious  state- 
ments about  her  periods,  and  that  married  women  often  make 
mistakes  about  their  condition  in  the  early  stages  of  pregnancy. 

The  Volsella*  in  Diagnosis.— The  speculum  enables  us 
to  see  the  vagina  and  the  cervix.  The  different  methods  of 
exploring  by  means  of  the  hands  and  fingers  afford  evidence 
of  the  condition  of  the  uterus  and  its  appendages,  as  far  as 

*  Vulsellum  is  wot  cla.'AHicaX.    In  Dr.  Siuitli's  Dictioiuuy  I  liml  "  Volsella.  re/. 

as  a  surgical  instrument, /ow^w,  Cels.  7,  12,  1";  and  under  Vulsella, 

''vide  Volsella. "     Strictly  speaking,  "  volsella  forceps "  is  a  pleonasm. 


THE    A'OLSELLA    IN    DIAGNOSIS.  77 

the  sense  of  touch  will  allow.  The  volsella  is  a  great  aid  to 
diagnosis.  The  uterus  is  very  movable  and  can  readily  be 
drawn  downwards.  When  drawn  downwards,  the  cervix  is 
brought  close  to  the  vulva,  and  may  then  be  examined  more 
satisfactorily,  at  least  as  regards  certain  conditions,  than 
through  a  speculum.  Again,  when  drawn  downwards,  the 
fundus  lies  lower  than  usual  in  the  pelvis,  and  thus  becomes 
easier  to  explore  by  rectal  examination  (page  71).  Hence,  the 
volsella  is,  by  itself,  an  important  aid  to  diagnosis,  and  is  likewise 
serviceable  when  employed  in  conjunction  with  other  methods. 

The  volsella  is  used  because  it  can  draw  down  the  uterus 
when  made  to  grasp  the  cervix,  and  can  do  so  without  inflicting 
pain,  owing  to  the  relative  insensibility  of  the  tissues  of  the 
cervix.  The  teeth  must  grasp  the  vaginal  aspect  of  the  cervix, 
and  must  hold  it  well,  else  they  will  tear  away  when  the 
surgeon  tries  to  draw  down  the  uterus. 

Many  varieties  of  volsella  have  been  devised.  A  strong 
instrument  is  needed  for  the  present  purpose,  and  it  must  be 
long  in  the  shanks  or  handle.  The  ovariotomy  volsella, 
described  further  on,  is  too  weak  for  drawing  down  the  cervix ; 
on  the  other  hand,  the  massive  instruments  designed  to  grasp 
uterine  fibroids  during  enucleation  are  equally  unsuited  for 
purely  diagnostic  purposes. 

The  volsella  should  not  be  used  before  a  careful  study  of  the 
history  of  the  case,  followed  by  digital  exploration  of  the  vagina 
and  cervix,  for  serious  injuries  may  be  inflicted  by  attempting 
to  draw  down  a  uterus  when  it  is  fixed  by  pelvic  inflammatory 
products,  or  when  cancer  of  the  cervix  exists.  If  employed  for 
the  diagnosis  of  displacements,  the  surgeon  must  remember  that 
it  is  in  itself  a  displacing  agent. 

On  the  other  hand,  the  volsella  is  very  valuable  in  exploring 
a  laceration  of  the  cervix.  The  speculum  is  apt  to  give  rise 
to  fallacies  with  regard  to  the  extent  of  this  kind  of  injury, 
as  ah'ead}''  explained.  The  volsella  affords  much  assistance 
in  the  diagnosis  of  the  relations  of  an  abdominal  tmnom*  to 
the  uterus. 

Diagnosis  by  aid  of  the  volsella  is  no  mere  refinement  of 
specialism.  The  surgeon  must  learn  how  to  use  the  volsella 
as  a  diagnostic   instrument.      If  he  fail  to  bear  this  in  mind, 


^8 


METHODS    OF    PELVIC    EXPLORATION. 


he  will  probably  fail  in  attempting  its  application  to  otber 
purposes.  Thus  the  volsella  is  indispensable  in  the  operation 
of  removing  the  cancerous  uterus  through  the  vagina.  In  the 
course  of  that  operation,  much  will  depend  upon  the  dexterity 
with  which  the  volsella  is  handled,  and  such  dexterity  must  be 
learnt  beforehand. 

How  to  use  the  Volsella  in  Diagnosis.— A  volsella 
like  that  represented  in  Fig.  23  will  be  found  convenient  for 
use  in  diagnosis.  It  bears  long  strong  teeth  which  grasp  well. 
Small  fine  teeth  are  not  so  readily  cleansed  after  operation.  It 
is  self-evident  that  any  instrument  which  inflicts  punctm-ed 
wounds  must  be  kept  scrupulously  clean.  When  the  surgeon 
desires  to  ascertain  the  conditions  and  connections  of  the  uterus, 
and  not  merely  to  explore  the  cervix,  the  patient  is  placed  on 
her  left  side,  and  the   ordinary  digital  exploration   is  made. 


Fig.   23.— Volkella. 


The  anterior  lip  of  the  cervix  is  touched  and  steadied  by  the 
right  forefinger  ;  it  is  best  to  keep  the  middle  finger  also  in 
the  vagina,  touching  the  os.  Gruided  by  one  or  both  fingers, 
the  volsella,  held  in  the  left  hand,  is  passed  up  to  the  anterior 
lip  and  made  to  grasp  it  antero-posteriorly.  The  tissues  must  be 
grasped  higher  up  in  front— that  is,  on  the  vaginal  aspect— than 
behind,  towards  the  cervical  canal,  else  pain  will  be  infl;icted  on 
the  patient.  The  volsella  is  now  drawn  do^^Ti,  pullino-  the 
uterus  with  it. 

Should  the  examination  be  made  to  ascertain  the  connections 
of  an  abdominal  tumour,  the  right  hand  is  placed  on  the  abdo- 
men over  the  tumour.  The  surgeon  then  attempts  to  tbaw 
down  the  uterus  by  means  of  the  volsella.  He  will  find  that 
the  tumour  moves  as  the  uterus  is  drawn  down,  or  else  remains 
fixed  whilst  the  uterus  resists  traction,  or  perhaps  remains  fixed 
whilst  the   uterus   descends   freely   dui-ing   moderate   traction. 


THE    VOLSELLA    IN    DIAGNOSIS TENTS.  79 

When  the  surgeon  wishes  to  explore  the  uterus  and  appendages, 
he  keeps  up  traction  with  the  volsella  held  in  the  right  hand, 
and  passes  the  left  forefinger  up  the  rectum.  The  fundus  may 
be  felt  in  that  manner,  the  cervix  being  drawn  a  little  forwards 
as  well  as  downwards.  As  the  cervix  descends,  the  surgeon, 
examining  through  the  rectum,  must  avoid  taking  the  supra- 
vaginal portion  for  a  tumour  or  a  "  little  cellulitis." 

For  exploring  a  suspected  fissure  of  the  os,  the  volsella  is 
absolutely  required,  but  a  Sims'  speculum  should  be  used, 
the  patient  being  placed  in  the  semi-prone  position.  In  that 
position,  it  is  true,  the  cervix  can  be  explored,  without  the 
aid  of  the  speculum,  by  drawing  it  down  with  the  volsella  and 
hooking  back  the  posterior  wall  with  the  left  forefinger.  The 
OS  can  then  be  brought  close  to  the  vulva.  This  simpler 
method,  however,  is  good  for  gaining  a  general  view  of  the 
cervix,  but  it  is  hardly  sufficient  for  exploring  a  fissure. 

Tents. — A  tent  is  a  rod  or  cone  made  of  some  material 
which  swells  under  the  influence  of  moisture.  When  intro- 
duced into  the  cervix  uteri,  the  tent  slowly  expands  the  cer- 
vical canal.  In  this  manner  the  uterine  cavity  becomes 
accessible  to  the  finger  for  diagnostic  purposes. 

The  use  of  the  tent  involves  evident  risks,  so  that  it  should 
never  be  employed  without  extreme  caution.  The  surgeon 
must  not  attempt  to  dilate  a  stenosed  cervix  or  to  straighten 
a  flexion  by  means  of  tents,  nor  to  introduce  a  tent  where 
there  are  evidences  of  pelvic  inflammation.  The  chief  use  of 
the  tent  is  in  the  management  of  some  of  the  after-conse- 
quences of  abortion,  or  of  the  retention,  after  natm-al  labour, 
of  products  of  conception.  The  tent  is  largely  employed 
by  some  specialists  for  facilitating  the  application  of  local 
remedies  to  the  endometrium,  or  for  allowing  of  the  scraping 
of  diseased  endometrium  by  the  curette.  In  more  essentially 
surgical  cases  it  is  rarely  required,  but  it  may  aid  the  surgeon 
in  exploring  polypi  and  other  intra-uterine  tumours. 

Tents  are  made  of  sponge,  of  a  seaweed  known  as  tangle 
{Laminaria),  and  of  a  wood  which  expands  under  the  influence 
of  moisture,  called  tupelo  {Nysm).  Sponge  tents  are  probably 
the  best  for  general  use.  Tupelo  tents  are  serviceable  when 
the  OS  externum  is  very  narrow.    A  tent  must  always  be  fur- 


80  METHODS  OF  PELVIC  EXPLORATION. 

uished  with  a  loop  of  tape  or  string  to  allow  of  its  withdrawal, 
and  the  surgeon  should  make  sure  that  the  loop  is  strong. 

Introduction  of  a  Tent. — This  must  never  be  done  in  a  con- 
sulting or  out-patient  room,  hut  always  in  a  hospital  ward 
or  in  a  private  patient's  bedroom.  The  patient  must  be  kept 
in  bed  whilst  the  tent  is  in  the  cervix,  and  for  some  time 
after  its  extraction.  The  tent  must  not  be  introduced  during 
a  monthly  period.  Before  introduction,  the  vagina  must  be 
purified  by  a  weak  carbolic  solution. 

The  tent  is  fixed  on  a  special  introducer  which  resembles 
a  sound,  and  when  lodged  in  the  cervix  it  is  detached  from 
the  introducer,  which  is  then  withdrawn.  Many  ingenious 
contrivances  have  been  devised  for  the  mechanical  detachment 
of  the  tent.  In  Barnes'  instrument  a  wire  runs  in  a  sheath ; 
the  tent  is  fixed  on  the  point  of  the  wire,  introduced  into 
the  cervix,  and  then,  by  pulling  the  handle  and  keeping  a 
finger  j^i'essed   on   the  lower  part   of    the  sheath,  the  wire  is 


I 


Fig.  24.— Tent  Ixtkoducer  or  Tent  Caiii:iei:. 

retracted  so  that  the  tent  is  disengaged  from  the  latter,  the 
upper  end  of  the  sheath  steadying  it  as  the  wire  slips  back. 
In  a  simpler  introducer  (Fig.  24)  the  tent  is  held  in  place 
by  the  forefinger  as  the  instrument  is  being  withdrawal. 
vSome  specialists  dispense  with  any  special  apparatus,  and  in- 
troduce the  tent  by  placing  the  patient  in  the  semi-prone  posi- 
tion, cbawing  down  the  cervix  mth  a  volsella  (seepages  69,  78), 
and  slipping  in  the  tent,  which  is  held  with  forceps ;  as  the 
cervix  has  been  drawn  down  close  to  the  vulva,  the  sm-geon 
can  make  sure  that  the  forceps  does  not  displace  the  tent  as 
its  blades  are  being  disengaged,  and,  indeed,  the  tent  can  be 
kept  in  place  by  the  forefinger  if  the  volsella  be  held  by  an 
assistant.  The  objection  to  special  introducers  is  the  difficulty 
of  insuring  their  cleanliness.  The  inexperienced,  however, 
will  find  that  the  introduction  of  a  tent  by  aid  of  the  semi- 
prone  posture  and  the  volsella  is  not  an  easy  task.  I  believe, 
however,  that  it  is  the  best  method. 


TENTS.  81 

Bisinfection  of  Toits. — Many  samples  of  tents  maj^  be  badly 
made,  or  insufficiently  impregnated  with  antiseptic  media. 
The  surface  of  a  tent  may  be  fissured,  so  that  septic  dust  or 
vaginal  mucus  may  lie  outside  the  substance  of  the  tent,  and 
be  introduced  into  the  cervical  tissues  lacerated  during  the 
process  of  dilatation.  To  remedy  the  pushing  forward  of  vaginal 
secretions,  the  vagina  must  be  syringed  out  before  the  tent  is 
introduced,  and  the  cervix  must  also  be  cleaned  by  wool 
fiistened  on  to  a  Playfair's  probe  and  soaked  in  a  weak  car- 
bolic solution. 

To  ensure  purity  of  the  tent  itself,  Dr.  Dirner,  of  Buda- 
Pesth,  keeps  laminaria  tents  immersed  in  a  1  per  cent, 
solution  of,  corrosive  sublimate  in  absolute  alcohol.  Provided 
the  alcohol  be  absolute,  the  expansive  property  of  the  tent 
is  not  impaired.  The  tent  is  taken  straight  out  of  the  solu- 
tion and  introduced  into  the  cervix  after  the  latter  and  the 
vagina  have  been  cleansed.  In  the  ease  of  a  hollow  tent, 
should  any  crystals  of  sublimate  lie  in  its  canal,  they  must 
be  washed  away  by  immersion  in  fresh  water. 

Removal  of  the  Tent. — The  tent  should  be  withdrawn  in  about 
twelve  hours,  then  the  vagina  must  be  freely  washed  out  with 
a  weak  carbolized  or  other  antiseptic  solution.  If  the  cervix 
be  not  sufficiently  dilated  for  the  desired  object,  another  tent 
will  be  needed.  There  is  always  more  risk  attendant  on  the 
introduction  of  a  second  or  third  tent,  as  the  structures  have 
ah'eady  been  injured. 

Rapid  dilators  of  the  cervix  should  never  be  used  except 
by  those  who  have  had  the  opportunity  of  seeing  them  em- 
ployed by  experienced  specialists,  and  noting  the  results  of 
their  employment. 


82 


CHAPTER  III. 

INSTRUMENTS    AND   APPLIANCES. 

Objects  of  this  Chapter.— The  sm-geon  must  not  only 
remember  what  instruments  he  may  need  for  operative  pur- 
poses, but  he  must  acquire  an  intelligent  knowledge  of  the 
precise  use  and  mechanism  of  every  knife,  forceps,  or  other 
appliance  which  he  may  be  called  upon  to  handle.  The 
technical  terms  applied  to  the  different  parts  of  an  instru- 
ment should  not  be  overlooked.  Since  there  is  so  much  to 
be  said  about  instrxunents,  many  will  be  described  in  this 
chapter,  and  chiefly  such  as  are  needed  in  ovariotomy,  hys- 
terectomy, and  to  a  less  extent  in  other  abdominal  sec- 
tions. The  description  of  the  steps  of  these  operations  must 
in  any  case  be  lengthy.  It  will  therefore  prove  highl}^  con- 
venient to  describe  the  instruments  first,  so  as  to  avoid  re- 
peated digressions,  which  would  greatly  extend  the  chapters 
on  Ovariotomy  and  Hysterectomy,  and  complicate  essential 
details  of  another  kind. 

In  the  course  of  operations  of  a  different  class,  especially 
plastic  procedures,  certain  instruments  are  requii'ed  which  are 
more  essentially  special  and  limited  in  utility.  As  the  de- 
scriptions of  such  operations  are,  as  a  rule,  relativel}'  brief, 
these  instruments  will  be  described  together  with  the  sm-gical 
proceedings  in  the  course  of  which  they  are  employed. 

Practical  Importance  of  Uniformity  in  Nomen- 
clature.— I  am  aware  that  many  standard  Enghsh  authori- 
ties trouble  very  little  about  the  names  of  instruments. 
Fergusson,  in  his  admirable  System  of  Practical  Savgery^ 
often  speaks  of  "an  instrument  such  as  here  represented,"  or 
*'  such  an  instrument  as  this."     I  have  reason  to  believe  that 


NOMENCLATURE TRAYS    FOR    INSTRUMENTS.  83 

this  practice  is  to  be  regretted.  In  the  country  or  in  the 
colonies  it  is  highly  important  for  the  surgeon  to  know  the  name 
of  an  instrument  which  he  desires  to  order  from  a  dealer  in 
this  or  any  other  country.  Besides,  it  is  very  objectionable 
to  have  to  ask  assistants  during  an  operation  for  the  "  what 
you  may  call  it,"  or  for  the  "bull-dog  forceps,"  the  latter 
term  being  understood  by  some  to  imply  the  full-sized 
"  Liston's  artery  forceps,"  and  by  others  to  signify  Dieffen- 
bach's  stout,  dwarf  "  cross-action  artery-forceps."  The  indif- 
ference to  nomenclature  displayed,  as  above  noted,  by  some 
hospital  surgeons  is  the  cause  of  the  multiplicity  of  names 
amongst  dealers.  Whilst  uj)holding  an  intelligible  nomen- 
clature for  practical  purposes,  I  think  that  terms  like 
"  Brown's  modification  of  Jones'  pessary  with  Eobinson's 
patent  stem  "  deserve  nothing  but  suppression. 

Trays  for  Instruments. — The  instruments  employed  in 
ovariotomy  should  always  be  kept  immersed  in  fluid  during  the 
course  of  the  operation.  If  the  operator  be  in  f  avoiu-  of  Listerian 
precautions,  the  fluid  will  be  a  1  in  40  solution  of  carbohc  acid. 
If  he  be  no  believer  in  Listerism,  pure  water  will,  according  to 
his  views,  be  sufficient.  The  solution  or  water  must  be  warm, 
and  should  be  poured  on  the  instruments  about  a  quarter  of  an 
hour  before  the  commencement  of  the  operation.  The  surgeon 
must  never  neglect  to  replace  every  instrument  in  the  fluid 
when  he  has  done  with  it.  It  is  not  advisable  to  allow  scalpels, 
needles,  and  forceps  to  collect  on  the  waterproof  sheet  below 
the  seat  of  operation.  In  this  case  some  of  the  instruments 
may  fall,  unobserved,  on  the  floor,  or  may  dro-p  into  the 
receptacle  for  the  fluid  under  the  table.  The  loss  of  a  pair  of 
forceps  in  this  manner  will  cause  trouble  and  anxiety  to  the 
operator  and  perhaps  risk  to  the  patient.  The  nurses  will  be 
obliged  to  search  with  their  hands  over  the  floor  around  the 
table.  They  may  also  be  compelled  to  thrust  their  arms  deeply 
into  the  fluid  in  the  receptacle.  A  pair  of  forceps  is  not  easily 
found  when  it  lies  at  the  bottom  of  several  gallons  of  dense 
fluid  mixed  with  solid  matter.  The  operator  may  think  that 
the  missing  instrument  is  in  the  abdominal  cavity,  and  even  go 
so  far  as  to  open  the  wound  afresh  and  disturb  the  viscera. 
Again,  instrimients  left  on  the  waterproof  sheet  are  never  so 


84  INSTKUMENTS   AND    APPLIANCES. 

readily  at  liand  as  when  they  are  careful!}^  replaced  in  the  trays 
towards  which  the  operator's  hand  is  instinctively  directed  when 
they  are  required.  Lastly,  if  the  instruments  be  kept  out  of 
the  fluid  after  use,  blood  and  morbid  products  will  dry  on  them, 
rendering  them  dangerous  to  use  diu-iug  the  operation  and 
difiicult  to  clean  afterwards. 

Basins  are  not-  good  receptacles  for  the  instruments.  If 
small,  the  longer  forceps  and  mounted  needles  cannot  be  com- 
pletely immersed,  nor  can  the  pressure-forceps  be  readil}'"  placed 
in  regular  order.  A  bunch  or  mass,  rather  than  a  row,  of  forceps 
mth  shanks  caught  in  bows,  or  with  bows  interlocking,  fouling 
Hgatures  and  mixed  up  with  threaded  needles,  mil  give  the 
operator  great  trouble.  On  the  other  hand,  the  high  sides  and 
everted  rims  of  a  big  basin  will  be  in  everybody's  way.  In 
any  case,  however,  a  basin  full  of  fluid  is  better  for  the  instru- 
ments than  a  chy  towel  or  a  bare  table. 

Thick  gutta-percha  trays  employed  by  some  operators  are 
clean,  durable,  and  in  many  ways  convenient.  Their  dark 
coloui',  however,  prevents  the  smaller  instruments,  especially 
suture  needles,  from  being  readily  seen.  In  hot  weather  and 
in  hot  rooms  they  become  soft  so  as  to  bend  when  grasped  at 
both  ends.  Tliis  may  cause  their  fluid  contents  to  be  suddenly 
spilt  at  some  inconvenient  moment.  Porcelain  dishes  are  good 
for  hospital  use,  but  are  heavy  and  liable  to  break. 

A  tray  made  of  block  tin,  about  two  inches  deep,  over  a  foot 
in  length  and  half  a  foot  in  breadth,  is  a  most  convenient 
receptacle  for  the  instruments  and  the  fluid  in  which  they  are 
immersed.  Two  such  trays  should  be  employed.  One  ^dll 
hold  the  pressure-forceps,  scattered  as  widely  and  arranged  as 
neatly  as  possible.  •  All  the  forceps  must  be  entirely  immersed. 

One  of  the  trays  should  bear  a  longitudinal  partition,  cutting 
off  a  small  space  for  the  ready-threaded  pedicle-needles.  Near 
the  top  of  the  same  tray  there  should  be  a  transverse  partition, 
which  will  cut  off  two  small  compartments.  In  the  larger  the 
reels  containing  three  or  four  different  thicknesses  of  silk 
should  be  placed.  They  must  revolve  on  a  thin  bar  of  metal 
fitted  to  the  sides  of  the  space.  This  arrangement  will  enable 
the  operator  to  dispense  vnih  a  special  contri\-ance  for  the  reels 
like  Lister's  carbolized  catgut  holder.     The  smaller  space,  cut 


TRAYS  FOR  INSTRUMENTS RECEPTACLE  FOR  FLVID.     85 

off  by  the  longitudinal  and  transverse  partitions,  will  con- 
veniently hold  the  needles  for  the  abdominal  sutures,  ready 
threaded  and  fastened  to  a  strip  of  gauze  neatly  rolled  up. 
The  largest  space  formed  by  the  longitudinal  partition  will 
hold  the  volsellse,  the  trocar,  and  other  large  instruments.  The 
tubing,  fitted  to  the  trocar,  may  be  rolled  up  in  the  tray.  It 
is  better,  however,  to  place  the  tubing  in  a  basin. 

Some  operators  employ  for  the  pressure-forceps  a  contri- 
vance resembling  a  square  tin  money-box  with  a  great  many 
slits  on  the  lid.  This  box  is  filled  with  fluid,  and  the  blades  of 
the  forceps  are  pushed  through  the  lids.  This  arrangement  is 
convenient  and  looks  neat,  but  I  do  not  like  to  see  the  handles 
standing  out  high  and  dry,  perhaps  stained  by  the  operator's 
fingers  or  by  ovarian  fluid.  These  soiled  forceps,  if  used  again 
and  possibly  kept  for  a  time  in  the  abdominal  cavity,  are  not 
conducive  to  the  patient's  welfare.  The  tray  is  far  better  for 
the  pressure-forceps  ;  it  permits  total  immersion. 

Directly  the  patient  has  been  seen  into  bed,  the  instruments 
should  be  carried  in  the  trays  into  the  next  room,  where  a  pan, 
a  basin  full  of  hot  water,  and  some  towels  should  be  at  hand. 
The  fluid  must  be  poured  out  of  the  trays  into  the  pan,  and 
the  instruments  are  then  dropped  into  the  basin.  The  trays  are 
then  dried  by  careful  rubbing  with  towels.  The  instruments 
must  next  be  rubbed  dry.  Particular  care  must  be  taken  to 
clean  the  teeth  and  the  hinges  of  the  pressure-forceps.  Then 
trays  and  instruments  should  be  packed  up. 

Receptacle  for  Ovarian  Fluid. — A  large  hip-bath  is 
the  most  convenient  receptacle  for  the  fluid  removed  from  an 
ovarian  tumour.  It  can  easily  be  kept  under  the  operating 
table  in  a  suitable  position.  When  the  trocar  is  thrust  into 
the  cyst,  care  must  be  taken  that  the  bath  stands  out  a  little 
towards  the  operator's  side  of  the  table,  so  that  the  tubing  may 
not  guide  the  stream  of  fluid  over  the  floor.  The  bath  must  be 
so  placed  as  to  receive  all  solid  matter,  which  is  removed  from 
the  cyst  by  the  operator's  hand  and  allowed  to  slip  doTv^l  one 
side  of  the  waterproof  sheet.  The  tumour,  when  severed  fi'oni 
its  connections,  should  never  be  thrown  into  the  bath.  This 
precaution  is  necessary  because  the  operator  often  leaves  pressure- 
forceps  and  volsellse  attached  to  its  walls.     These  instruments 


86 


INSTRUMENTS   AND   APPLIANCES. 


are  easily  found  in  a  basin,  but  ai'e  onlj  to  be  recovered  with 
great  trouble  in  a  bath. 

Objectionable  as  it  may  be  to  search  the  bath  for  fluid,  this 
must  be  done  when  instruments  are  missing.  Now  and  again 
forceps  will  slip  down  unobserved,  so  that  when  missing  after 
the  abdominal  wound  has  been  sewn  up,  they  must  be  looked 
for  in  the  bath  and  elsewhere  before  the  operator  resorts  to  the 
painful  alternative  of  opening  the  wound  afresh. 


Fig.  25. — Weistlets  on  Handcuffs,  with  Strap  for  PA,ssI^o  itnder  the 
Operation  Table. 

Wristlets  and  Straps. — Some  operators,  as  Sii'  Spencer 
Wells,  prefer  to  fix  the  wrists  of  the  patient,  before  an 
abdominal  section,  by  bandages,  passed  in  clove-hitch  knots 
aromid  the  wrists  and  made  fast  to  the  legs  of  the  table.     A 


Fic.   26.— Tiiicii-Hi-.LT. 

jack-towel  may  be  made  to  serve  as  a  strap  to  keep  down  the 
knees.  However,  the  wristlets  represented  in  Fig.  25  are  very 
convenient.  The  strap  is  passed  under  the  table  and  length- 
ened  or   shortened    so   that   the  -vvrists   are    held  well   down. 


STRAPS — MIRROR WATERPROOF  SHEET.  87 

Fig.  26  represents  a  good  tMgh-belt,  passed  above  the  patient's 
knees  and  made  fast  under  the  table  by  the  two  straps.  It 
is  important  that  these  straps  be  examined  from  time  to 
time,  else  one  or  both  may  snap  in  the  middle  of  an  opera- 
tion. 

Mirror. — A  hand-glass  is  very  useful  for  throwing  artificial 
light  into  the  abdominal  cavity  on  a  dark  day,  or  for  reflecting 
the  light  of  the  sun,  when  that  luminary  is  shining,  into  dark 
recesses. 

The  Waterproof  Sheet. — This  contrivance  is  necessary 
in  order  to  protect  the  patient  and  her  clothes  from  ovarian 
and  other  fluids,  which  escape  through  the  abdominal  wound  in 
the  course  of  the  operation.  When  it  is  evident,  before  the 
abdominal  incision  is  made,  that  there  is  much  fluid,  or  that  a 
large  semi-solid  tumour  has  to  be  removed,  the  sheet  is  almost 
indispensable.  On  the  other  hand,  when  the  abdomen  is  not 
distended,  and  nothing  but  a  small  pelvic  tumour  or  a  cyst 
containing  barely  a  pint  of  fluid,  or  a  bulky  but  perfectly  solid 
tumour,  is  likely  to  be  found,  the  sheet  is  in  the  way.  I  shall 
Tefer  to  this  matter  in  the  chapters  on  Oophorectomy  and 
Hysterectomy. 

The  waterproof  sheet  should  consist  of  a  large  piece  of 
mackintosh,  measuring  about  two  square  yards.  An  oval  hole, 
about  eight  inches  in  length  and  six  in  breadth,  is  cut  in  this 
sheet,  so  as  to  leave  about  one  foot  of  sheeting  between  its 
upper  extremity  and  the  upper  border  of  the  sheet.  In  other 
words,  it  must  be  near  one  end  of  the  sheet,  and  that  end  is 
to  be  placed  uppermost,  protecting  the  epigastrium,  and  the 
dress  over  the  thorax.  The  longer  part  of  the  sheet,  below 
the  hole,  covers  the  thighs  and  knees,  extending  nearly  to 
the  feet;  the  sides  of  the  sheet  hang  over  the  sides  of  the 
table.  The  under  or  rough  side  of  the  edge  of  the  hole  is 
smeared  with  carbolized  adhesive  plaster  in  a  layer  about  an 
inch  wide. 

This  plaster  is  the  emplastrum  resinse  B.P.  Sixteen 
parts  of  lead  plaster,  melted  at  a  low  temperature,  are  mixed 
with  two  parts  of  resin  and  one  part  of  cm'd  soap.  The  mass 
is  stirred  until  the  ingredients  are  thoroughly  mixed,  and 
2  per  cent,  of  melted  carbolic  acid  crystals  is  added  as  this  is 


88  INSTRUMENTS    AND    ArPLIANCES. 

teing  done.  Amateur  and  inexperienced  dispensers  sometimes 
neglect  the  dii"ection  about  the  lead  plaster,  and  make  it  too 
hot ;  the  compound  will  then  be  of  insufficiently  firm  consist- 
ence, and  very  unsuitable  for  the  waterproof  sheet. 

The  hair  of  the  pubes  should  be  cut  short  or  shaved  before 
the  application  of  the  sheet.  The  nurse  must  take  the  two 
upper  ends  of  the  sheet  in  her  hands,  holding  them  across  the 
patient's  chest  or  epigastrium.  The  operator  then  guides  the 
sheet  so  that  the  lower  end  of  the  hole  lies  on  the  abdomen 
just  above  the  pubes,  the  margins  of  the  hole  being  carefully 
approximated  to  the  sides  of  the  abdomen,  and  the  upper  limit 
carefully  fixed  to  the  abdomen  above  the  umbilicus.  In  fact, 
the  concavity  of  the  j)rominent  abdomen  must  fit  the  hole. 
This  must  be  done  carefully,  else  the  plaster  will  smear  the 
integuments  unnecessarily,  especially  towards  the  flanks.  To 
adjust  the  edges  accurately  to  the  integuments,  without  getting 
his  fingers  sticky  with  plaster,  the  surgeon  should  hold  a 
corner  of  the  sheet  and  press  it  gently  against  the  edge  of 
the  hole,  wherever  the  adhesion  aj^pears  to  be  faulty.  This 
precaution  is  most  necessary  in  the  hypogastric  region.  Should 
the  apron  adhere  imperfectly  in  that  region,  it  may  come 
undone  for  an  inch  or  two  as  the  cyst  collapses,  and  then 
several  pints  of  fluid  may  escape  under  the  sheet  and 
drench  the  patient's  thighs  and  nates.  A  similar  accident 
may  occur  when  the  peritoneal  cavity  is  flushed  with  warm 
water. 

It  is  advisable  that  the  long  diameter  of  the  hole  be  not 
too  short.  Otherwise,  should  the  tumour  be  much  larger  than 
expected,  the  operator  will  have  to  cut  through  integmnents 
soiled  with  adhesive  plaster.  In  some  cases,  however,  this 
must  be  done.  Grreat  care  must  be  taken  lest  a  dirty  sheet 
be  used.  The  sheet  must  be  well  washed,  after  every  opera- 
tion, with  some  antiseptic  fluid,  and  all  trace  of  blood-stains 
must  be  scrubbed  away ;  the  under  sirrface  will  especially 
require  attention. 

During  the  operation,  since  a  large  surface  of  the  sheet 
hangs  over  each  side  of  the  table,  the  operator  may  freely  let 
fluid  and  semi-solid  matter  escape  from  the  abdominal  cavity 
and  fall  into  the   receptacle    under  the  table.      The  assistant 


WATERPROOF    SHEET SPONGES.  89 

must  guard  against  any  overflow  on  his  side,  or  below  the 
pubes,  by  raising  the  edge  of  the  sheet,  so  as  to  direct  the 
current  of  escaping  material  towards  the  operator's  side,  in  such 
a  manner  that  the  fluid  crosses  the  sheet  below  the  hole,  else 
it  will  get  into  the  abdomen  again.  This  manoeuvre  is  espe- 
cially necessary  when,  for  any  reason,  much  fluid  is  allowed 
to  escape  without  the  aid  of  the  trocar  and  cannula. 

The  Sponges. — A  good  set  of  sponges  must  always  be  at 
hand  when  an  ovariotomy  is  about  to  be  performed.  Although 
a  large  number  is  liable  to  give  trouble  when  the  sponges  are 
counted,  the  difficulties  when  they  are  too  few  will  be  greater. 
Towards  the  end  of  any  operation  most  of  the  sponges  will 
be  out  of  use,  and  should  be  placed  in  a  basin,  the  nurse 
covmting  them  carefully.  The  remainder  will  be  in  the 
operator's  and  assistant's  hands,  or  in  the  abdominal  ca\dty,  and 
possibly  a  sponge  may  lie  somewhere  where  it  should  not  be — 
on  the  floor,  or  in  the  receptacle  for  ovarian  fluid,  for  example. 
As  the  missing  sponges  will  be  few  in  number,  the  search  for 
them  will  seldom  be  very  difficult.  Other  precautions  will  be 
noted  when  the  operation  of  ovariotomy  is  described. 

An  insufficient  supply  of  sponges  will  give  great  trouble  if 
the  operation  be  long,  or  if  sudden  hsemorrhage  or  effusion  of 
ovarian  fluid  into  the  peritoneal  cavity  occur.  The  nurses  will 
then  have  difficulty  in  washing  out  the  sponges  quickly  enough, 
and  the  cleansing,  done  in  haste,  will  most  probably  be  imperfect. 
Hence  the  operator  must  be  well  supplied  with  sponges. 
Twenty  is  a  good  number.  Of  these,  four  should  be  broad  and 
thin,  and  in  two  pairs  of  different  sizes.  They  should  be  known 
to  the  operator,  assistants,  and  nurses  as  "  the  large  flat  sponges," 
and  "  the  small  flat  sponges."  Ten  should  be  large  toilet 
sponges,  never  so  big  as  to  approach  a  bath  sponge  in  size,  but 
sufficiently  bulky  to  soak  uj)  blood  and  fluid  well.  The  remain- 
ing six  should  be  somewhat  smaller,  and  distinctly  conical. 
These  may  be  used  as  "  stick-sponges  " — that  is,  they  may  be 
mounted  on  holders,  if  necessary,  when  distant  recesses  of  the 
peritoneum  require  cleansing.  They  must  never  be  as  small  as 
the  sponges  often  used  in  plastic  operations. 

Frcparation    of  Neu-    Sponges. — The    operator   must    always 
inspect  newly-purchased  sponges.     They  must  not  be  boiled, 


90  I>'STRUMEM'S    AND    APPLIANCES. 

since  that  causes  them  to  become  rough  and  in-itating  to  the 
peritoneum.  To  rid  them  of  sand,  they  should  be  packed  in 
calico  bags,  and  well  beaten  about  and  shaken.  Then  the}' 
must  be  put  into  a  basin  of  warm  water,  and  allowed  to  soak  all 
day.  They  can  then  be  taken  out  and  di-ied,  and  kneaded  in  the 
nurse's  hands,  so  that  it  can  be  made  sure  that  all  sand  and  grit 
has  been  expelled.  Should  any  such  material  remain,  the  sponge 
which  is  found  to  contain  it  must  be  put  into  warm  water  again. 
After  this  process  is  completed,  the  sponges  must  be  immersed 
for  twelve  hours  in  a  1  in  5  solution  of  sulphurous  acid. 
This  will  make  them  look  very  clean,  and  will  in  reality  free 
them  from  all  organic  impurities. 

Management  of  Sponges  after  Operation. — It  is  dangerous  to 
have  a  double  set  of  sponges  in  use  when  two  operations  are 
performed  consecutively  in  a  hospital.  In  such  a  case  it  is 
advisable  to  set  aside  any  sponge  which  has  been  fouled  in  the 
course  of  the  first  operation,  and  to  employ  the  remainder  of  the 
same  set  for  the  second,  the  rejected  sponge  being  remembered 
when  the  others  are  once  more  counted. 

All  sponges  which  have  only  been  stained  by  ordinary  ovarian 
fluid  or  blood  can  be  thoroughly  cleansed  by  immediate  immer- 
sion m  hot  water,  with  free  squeezing.  When  a  sponge  has 
been  fouled  by  contact  "svith  pus,  fseces,  gangrenous  tissue,  or 
any  other  deleterious  fluid  or  solid  material,  it  must  be  at  once 
placed  in  the  sulphurous  acid  solution  mentioned  above,  and 
left  there  for  twelve  hours. 

The  greasy  contents  of  dermoid  cysts  render  sponges  very 
difficult  to  clean.  In  this  case  the  best  cleansing  material  is  a 
drachm  of  carbonate  of  soda  dissolved  in  a  quart  of  warm  water  ; 
the  sponges  must  be  well  squeezed  out  after  immersion  for 
half-an-hour  in  this  solution. 

Under  no  circumstances  must  sponges  be  boiled,  or  even 
di'opped  into  boiling  water,  or  washed  in  soap,  or  left,  for 
however  short  a  time,  out  of  warm  water,  or  any  other  necessar}' 
cleansing  fluid,  after  the  operator  or  assistant  has  handed  them 
to  the  nurse.  The  water  need  never  be  heated  much  over  100'. 
This  temperature  is  sufficient  for  mechanical  cleansing,  and 
does  not  injure  the  tissue  of  the  sponges.  Very  hot  water 
initates  the  hands  of  the  nurses ;  sometimes,  as  I  have  seen,  it 


SPONGES THE    SCALPEL.  91 

may  cause  severe  eczema,  rendering  a  nurse  totally  unfit  to 
attend  a  patient  for  weeks. 

Nurses  and  Sponges. — That  inexperienced  and  unintelligent 
nurses  may  not  only  be  careless,  but  even  unable  to  count 
properly,  tbere  can  be  no  doubt,  for  facts  have  proved  this 
supposition.  Many  persons,  in  counting  a  set  of  objects,  hold 
a  sample  in  their  hands,  and  neglect  to  count  it,  or  begin  with 
it  as  "number  one,"  and  count  it  again  at  the  end.  The  fact 
that  the  unintelligent  count  badly,  has  been  recogmzed  in 
Eui-opean  folk-lore.  The  Grermans  tell  a  tale  of  seven  peasants 
who  forded  a  river  in  a  dense  fog.  When  they  had  reached 
the  further  side  each  began  to  count  his  companions,  neglecting 
to  include  himself  in  the  muster.  Hence  they  aU  concluded 
that  as  only  six  could  be  counted  one  must  have  been  drowned, 
but  to  the  day  of  their  deaths  could  never  make  out  which  of 
their  number  perished  in  the  stream.  They  had  fallen  into  a 
mathematical  error,  much  more  frequently  committed  by  nurses 
counting  sponges.  I  have,  on  more  than  one  occasion,  observed 
a  nurse  uncertain  whether  she  had  or  had  not  counted  a  sponge 
which  she  had  pertinaciously  held  in  her  fingers.  To  avoid 
this  accident,  the  counter  should  never  hold  any  one  sponge. 
The  best  method  of  counting  will  be  presently  described. 

The  Scalpel. — A  good  stout  scalpel  is  the  most  suitable 
knife  for  making  the  abdominal  incision.  If  too  small  and 
narrow-bladed,  the  incisions  which  it  makes  are  apt  to  be  tailed 
or  jagged,  the  point  penetrates  too  deeply,  and  the  edge  does 
not  cut  deep  enough.  The  want  of  weight  in  the  instrument 
renders  it  difficult  for  guidance  by  the  hand.  In  opposite 
respects,  a  breast-knife  is  not  advisable.  That  instrument  is 
made  for  free-handed  sweeping  incisions  over  wide  planes  of 
firm  tissue,  and  the  cutaneous  wounds,  in  the  operations  for 
which  it  is  designed,  are  meant  to  be  made  freely  and  deeply, 
nor  do  they  require  such  precise  delicacy  of  manipulation  as  do 
incisions  through  the  linea  alba.  Its  heavy  blade  may  cut 
through  two  layers  of  the  abdominal  wall  when  the  operator 
intends  only  to  divide  one.  There  is  a  great  difference  between 
cutting  over  the  peotoralis  major  muscle  and  the  ribs,  and 
making  incisions  over  peritonemn,  cysts,  and  viscera.  In 
short,    a   scalpel,  the   size   of   a  large  dissecting  knife,  but   a 


92 


INSTRUMENTS    AND    Al'PlJANCES. 


little  heavier,  will  prove  a  happy  medium  between  a  cutting 
instrument  too  small  and  another  too  large,  for  the  piu"pose  of 
la}dng  open  the  abdominal  wall.  Yet  individual  hands  have 
their  idiosyncrasies,  and  there  are  surgeons  who  prefer  un- 
usually heavy  or  light  knives  for  this  kind  of  work. 

The  Scissors.  —  The  best  form  of  scissors  for  the 
ovariotomist  is  a  very  strong  pair,  bent  and  not  curved  on 
the  flat  (Fig.  27).  The  ends  must  be  quite  blunt  and  well 
rounded,  the  edges  should  be  kept  sharp.  This  instrument  is 
indispensable  at  the  simplest  ovariotomy.  There  is  an  idea 
still  prevalent  that  scissor  wounds  do  not  heal  by  fii-st  intention, 
and  that  the  margins  tend  to  become  sloughy,  but  the  free 
borders  of  ovarian  pedicles  do  not  slough,  though,  at  the 
Samaritan  Hospital  at  least,  the  pedicle  is  always  divided  with 
scissors ;   and  I  have  seen  over  a  hundred  abdominal  wounds 


Fii;.  27. — Scissors  for  Ovariotomy,  bent  on  the  Flat. 


enlarged  upwards  by  scissors,  and  they  never  appear  to  unite 
badly  in  consequence. 

The  stoutness  and  size  of  the  scissors  make  them  manage- 
able, and  the  bent  blades  allow  them  to  be  freely  phed, 
whilst  the  operator's  hand  is  kept  out  of  the  way  of  the 
structm-es  which  they  divide.  The  blades  must  not  be  curved, 
for  if  they  be  so,  it  will  be  difficult  to  enlarge  the  wound 
properly,  and  in  dividing  the  pedicle  too  much  or  too  little 
of  the  stump  may  be  cut  away.  The  bluntness  aud  thickness 
of  the  ends  avoid  damage  to  the  intestines  and  other  delicate 
structures — they  push  things  away  instead  of  catching  them. 
Nevertheless,  of  course,  the  surgeon  must  take  care  lest  certain 
structures  get  between  the  blades. 

It  is  in  the  division  of  the  pedicle  that  the  scissors  are  most 
needed.  They  are  far  less  liable  to  cause  accidents  than 
are    scalpels   and   other   knives,   however   blunt-pointed.      As 


SCISSORS FORCEPS FORCIPRESSURE.  93 

the  assistant  holds  the  two  pressui-e-forceps,  which  are  fixed  to 
each  border  of  the  pedicle  in  the  manner  directed  in  the 
account  of  the  operation,  the  surgeon  cuts  straight  between 
the  forceps.  The  very  act  of  cutting  properly  will  be  much 
easier  with  the  scissors  than  with  a  scalpel.  In  enlarging  the 
abdominal  wound  upwards  the  scissors  should  always  be 
preferred  to  the  knife ;  they  cut  straight  and  involve  less 
danger  to  deep  structures.  Omental  and  other  adhesions  are 
far  better  divided  by  scissors.  A  piece  of  cyst- wall  which  has 
to  be  left  on  a  portion  of  intestine,  liver,  or  other  structure,  to 
which  it  is  too  firmly  adherent  to  be  detached  with  safety, 
should  also  be  cut  away  by  scissors  from  the  removable  part  of 
the  cyst.  The  same  instrument  should  be  used  in  enlarging 
the  trocar  wound  in  the  cyst- wall,  or  in  cutting  through  tough 
loeuli. 

The  Forceps.* — An  artery-forceps  of  the  familiar  Liston- 
Coxeter,  or  fenestrated  variety,  should  be  at  hand  when  an 
abdominal  section  is  performed.  It  is  required  when  a  large 
vessel  needs  ligature.  For  ordinary  purposes,  forcipressure  is 
far  preferable  to  ligature,  in  the  course  of  operations  on  the 
female  organs.  Forcipressure  generally  avoids  the  necessity 
of  leaving  ligatures  in  the  abdominal  wound,  and  the  pressure- 
forceps,  by  means  of  which  it  is  effected,  is  particularly 
suited  for  application  to  the  wound. 

Sir  Spencer  Wells  appears  to  have  been  the  first  to  secure,  as 
a  matter  of  routine,  bleeding  vessels  in  the  abdominal  cavitj^  by 
simply  seizing  them  with  artery-forceps,  and  taking  the  forceps 
off  towards  the  end  of  the  operation,  without  applying 
ligatures,  t  He  had  found  that  ligatm^e  was  needless  after 
temporary  application  of  the  small  but  strong  bulhdog  forceps. 
In  1865,  Vemeuil  adopted  the  system,  and  gave  it  its  name, 
forcipressure,  but  Koeberle  had,  a  few  years  previously,   first 

*  "Forceps"  is  often  used  as  though  it  were  invariably  plural,  like  "scissors." 
This  is  incorrect.  In  Smith's  Latin  dictionary  I  find  "  Forceps,  cipis, 
VI.  &/.,  a  pair  of  tongs,  pincers,  forceps."  Donaldson  derives  it  from /oris  and 
ca2no,  the  first  syllable  referring  to  the  "opening,"  or  "door,"  which  this 
instrument  makes  to  grasp  the  object.  There  appears  to  be  no  authority  for 
using  a  spurious  singular  form,  "forcep." 

t  "  Remarks  on  Forcipressure  and  the  Use  of  Pressure-Forceps  in  Surgery  " 
(British  Medical  Journal,  vols.  i.  and  ii.,  1879). 


94  INSTRUMENTS    AND    APPLIANCES. 

employed  the  earliest  special  pressm'e-forceps,  made  with  long 
handles,  so  that  it  could  not  readily  be  lost  in  the  abdominal 
cavity.  He  soon  dispensed  entirely  with  the  ligatm'e.  Pean 
was  another  of  the  principal  introducers  of  forcipressure. 
The  fact  is  now  well  established  that,  when  the  end  of  a  small 
artery,  of  the  kind  so  frequently  divided  in  thj  course  of  an 
abdominal  section,  is  seized  by  the  forceps,  htemorrhage  will  be 
definitely  checked,  provided  that  the  instrument  be  left  on  for 
five  minutes,  or  longer  if  desired. 

Several  different  patterns  of  pressure-forceps  are  in  use  and 
are  often  confounded.  I  shall  therefore  describe  the  principal 
varieties.  Instrument  makers  do  not,  I  find,  employ  a  unifoim 
system  of  nomenclature  for  the  parts  of  a  forceps.  It  may  be 
said  to  consist  of  two  "blades,"  bearing  "teeth"  and  terminating 
in  a  "  nozzle  "  or  "  point  "  ;  of  two  "  shanks  "  continuous  -svith 
the  blades,  connected  by  a  "  pivot "  or  "  axis,"  and  made  fast 
when  closed  by  a  "ratchet "  or  catch,  bearing  "  teeth"  ;  and  of  a 
pair  of  "  bows  "  or  "  rings."  The  term  "  handle  "  is  confusing. 
I  have  heard  it  applied  indifferently  to  the  shanks  and  to  the 
bows. 

Koeberle's  Pressure  -  Forceps. — The  oldest  form  of 
pressure-forceps  is  Koeberle's  (Fig.  28) .  This  instrument  has 
not  such  a  finished  look  as  the  later  forms,  and  is  the  longest, 
measuring  about  five  and  a  half  inches.  The  blades  have 
regular  teeth,  interrupted  by  two  deep  grooves  and  two  dejires- 
sions.*  The  shanks  are  broad  and  very  flat,  and  run  for  nearly 
an  inch  below  the  pivot.  Instead  of  a  ratchet  there  is  a  short 
pin  or  projecting  point  on  one  shank  close  below  the  ring  ;  this 
pin  has  two  corresponding  holes  on  the  opposite  shank.  When 
the  instrument  is  closed  at  the  first  hole  there  is  a  gap  half  an 
inch  long  between  the  shanks.  The  rings  are  small  and  not 
bevelled,  as  now,  though  not  I  believe  as  at  fii'st,  constructed ; 

*  ilany  surgeons  appear  to  be  unaware  tliat,  as  Mr.  Hawksley,  the  surgical 
instrument  maker,  has  pointed  out  to  nic,  the  grooves  and  depressions  often 
found  on  the  blades  of  dressing-forceps  were  originally  intended  to  adai)t  the 
blades  to  hare-lip  pins  or  suture-needles  held  cross-ways  or  longitudinally,  so 
that  the  forceps  might  be  used  as  a  needle-holder  if  desired.  The  pressure- 
forceps  was  evolved  from  the  dressing-forceps,  so  that  the  grooves  in  Koeberle's 
variety  are,  as  it  were,  Darwinian  relics.  I  find  that  this  variety  of  pressure- 
forceps  is  sometimes  described  as  a  "needle-hohling  forceps  with  spring  catch." 


KOEBERL^'s   FORCEPS PEAn's    FORCEPS. 


95 


the  shanks  can  be  unfastened  at  the  pivot  for  cleaning. 
Though  the  gap  between  the  shanks  is  so  small  as  not  to  be  of 
any  serious  import,  this  form  of  pressure-forceps  is  not  satis- 
factory, as  the  pin  and  holes  are  not  nearly  so  trustworthy  as 
the  ratchets  of  the  later  forms.      Its  designer,  however,  deserves 


Fig.  28. — Koeberl:6's  Peessltre-Foeceps. 

honour  for  being  first  in.  the  field,  though  the  method  had  been 
already  employed  before  any  special  instrument  was  invented. 

Pean's  Forceps. — This  instrument  was  first  constructed, 
under  M.  Pean's  directions,  by  M.  Grueride  in  the  year 
1868.  Its  chief  feature  is  its  extreme  lightness.  The  blades 
have  even  teeth,  and  are  not  flattened  on  the  planes  of  the  ends 
of  the  pivot.  Their  outer  surface  is  not  very  convex,  but  the 
point  is  fairly  sharp.  The  grip  of  the  blades  is  weak.  The 
shanks  are  nearly  one  inch  long  between  the  blades  and  the 
pivot,  but  comparatively  short,  in  relation  to  Wells'  and  Taits' 
forceps,  above  the  pivot,  where  they  are  very  slender  and 
separated  by  a  wide  elhptical  space  even  when  they  are  closed 
by  the  second  catch  of  the  ratchet.  The  shanks  can  be 
unfastened  at  the  pivot.  This  is  important  for  ensuring  clean- 
liness when  the  instrument  is  not  immersed  in  carbolic  solu- 
tions or  in  pure  water,  after  the  custom  of  ovariotomists.  In 
the  latter  case  this  arrangement  is  not  necessary.  The  rings 
of  Pean's  forceps  are  wide  and  thin,  and  the  ratchet,  which  is 
double-toothed,  lies  immediately  below  them.  This  instrument 
was  one  of  the  first  of  the  kind  in  the  field,  and  M.  Pean 
deserves  well  of  surgery  for  designing  and  employing  it  and 
advocating  its  use.  It  is,  however,  more  suited  for  general 
surgery  than  for  ovariotomy.  Its  blades  and  rings  are  too 
thin  and  sharp,  and  may  readily  tear  omentum.      It  is  too 


J^6  INSTRUMEXTS    AND    APPLIANCES 

liglit,  SO  that  it  easily  gets  pushed  about  when  the  surgeon 
sponges  the  peritoneum,  or  displaced  when  he  flushes  its 
cavity  with  hot  water.  Then,  when  it  cannot  be  found  with- 
out search,  it  is  not  so  easy  to  detect  rolled  up  in  omentum  or 
bm'ied  under  viscera,  as  the  blunt,  heavy  instruments  presently 
to  be  described.  The  weak  pressure  of  its  blades  when  closed 
is  no  bad  feature.  I  do  not  believe  in  a  needlessly  firm  grip  of 
the  forceps.  The  worst  featiu-e  of  Pean's  forceps  is  the  wide 
gap  between  its  slender  shanks,  which  may  readily  cause  the 
entanglement  of  a  piece  of  omentum. 

Spencer  Wells'  Pressure-Forceps  (Old  Form). — Sir 
Spencer  Wells'  original  pressure-forceps  (Fig.  29)  must  next 
be  described.  This  instrmnent  is  over  five  inches  in  length 
and  very  heavy.       The   blades,   nearly   an   inch   long,   begin 


Fig.  29. — Spenx'er  "Wells'  Pressure-Forceps  {old  form). 

immediately  below  the  pivot.  They  are  flattened  abruptly  below 
the  pivot  on  the  anterior  and  posterior  aspects,  whilst  laterallj^ 
they  are  only  slightly  convex.  The  point  is  blunt  and  the 
grip  very  firm.  The  shanks  are  long  and  differ  from  those 
of  all  the  other  fonns  in  that,  owing  to  the  construction  of 
the  hinge,  where  one  shank  passes  through  a  slit  in  the  other, 
they  appear  to  lie  almost  parallel  to  each  other  when  the 
instrument  is  closed,  and  their  opposite  surfaces  are  perfectly 
flat  and  about  an  eighth  of  an  inch  in  breadth.  The  shanks, 
too,  are  exceedingly  stout.  The  ratchet  is  of  the  kind  known 
to  instnmient  makers  as  Matthieu's  catch.  It  has  only  one 
tooth,  and  lies  between  the  rings,  which  are  not  bevelled. 
When  the  instrument  is  closed,  a  slit  about  three  inches  long 
and  an  eighth  of  an  inch  at  the  widest  hes  between  the  wide 
flat  inner  surfaces  of  the  blades. 

This  is  a  highly  finished  instrument,  and  when  it  is  placed 


wells'  pressure-forceps.  97 

entirely  within  the  peritoneal  cavity  its  weight  prevents  it 
from  being  easily  pushed  about  during  subsequent  manipula- 
tions. The  stoutness  and  bluntness  of  its  shanks  are  designed 
to  avoid  any  tearing  or  bruising  of  dehcate  structures.  Of 
course,  heavy  though  this  instrument  may  be,  the  weight  of 
any  pair  of  forceps  of  similar  size  could  never  be  sufficient 
in  itself  to  damage  internal  organs.  The  chief  objection  to 
this  variety  is  the  wide  gap  between  the  shanks.  The  flatness 
of  the  inner  surfaces  of  the  shanks  renders  accidents  to  en- 
tangled structures  less  likely,  no  doubt,  than  under  similar 
circumstances  when  Pean's  forceps  is  employed,  where  the 
inner  edges  of  the  shanks  feel  quite  sharp.  Still,  Sir  Spencer 
Wells  has  recognized  this  disadvantage  of  the  gap,  and  dis- 
carded this  variety  for  a  new  form. 

Spencer  Wells'  Pressure -Forceps   (New  Form). — 
Wells'  new  pressure-forceps    (Fig.  30)  is  Hghter  and  slightly 


Fig.  30. — Wellh'  Pressure-Forceps  {new  form). 

shorter  than  the  former  kind  also  employed  by  that  ovarioto- 
mist.  It  is  also  more  like  the  varieties  designed  by  other 
surgeons  in  general  construction,  but  is  much  heavier  than 
Koeberle's.  The  blades  are  slender  and  flattened  but  not 
abruptly  on  the  aspects  of  the  ends  of  the  pivot ;  the  lateral 
aspects  are  distinctly  convex.  The  shanks  are  slender,  and 
so  constructed  that  the  upper  entii'ely  and  accurately  covers 
the  lower  when  the  catch  or  ratchet  is  closed  at  the  second 
tooth.  The  ratchet  lies  half  an  inch  below  the  rings,  and 
has  two  strong  teeth.  The  rings  are  small,  stout,  and  well 
bevelled.  This  is  an  excellent  instrument ;  it  is  not  too  light, 
and  there  is  no  space  between  the  shanks.     Sir  Spencer  Wells 


98  INSTRUMENTS    AND   APPLIANCIES. 

states  that  this  latter  defect  has  been  completely  corrected 
without  at  all  lessening  the  compressing  power  exerted  on  the 
vessel.  He  adds : — "  In  October,  1878,  Mr.  Hawksley  care- 
fully tested  the  compressing  power  of  different  forceps  when 
opened  by  a  piece  of  leather  one  millimetre  thick  between  the 
jaws  of  the  forceps,  and  covering  about  fom*  teeth  from  the 
points.     The  following  table  gives  the  result : — 

"  Poumh  avoirdupois  exerted  hy  four  feetJi  of  flie  end  of  forcepa 
irJien  one  millimetre  apart. 

Forceps.  First  Catch.  Second  Catch. 

Koeberle —         3^ 

Pean    8  12 

S.  Wells  (old)    ....         18         — 

„       (new)    ....       5—7        15—17 

"  It  may  be  seen  that  in  my  old  instrument  there  is  only  one 
catch,  and  in  my  new  one  the  second  catch  only  exerts  the 
same  power  as  the  first  catch  of  the  old  instrument.  But 
this  is  five  times  greater  than  the  second  catch  in  Koeberle's, 
and  one-third  more  than  that  of  Pean's.  When  only  the 
first  catch  in  Koeberle's  instrument  is  closed,  the  points  are 
separated  about  half  a  centimetre,  so  that  they  only  compress 
anything  more  than  that  in  thickness." 

Mr.  Hawksley  informs  me  that  the  mechanism  by  which 
the  shanks  accurately  overlap  when  closed  at  the  second  tooth 
of  the  ratchet  was  designed  entirely  for  the  purpose  of  attain- 
ing the  strongest  possible  amount  of  pressm-e,  and  not  for 
obliterating  the  space  between  the  shanks.  It  must  be  remem- 
bered that  it  is  not  when  the  vessel  is  being  seized  and  the 
forceps  closed  that  there  is  any  danger  from  structm-es  falling 
between  the  shanks.  That  accident  occurs  when  the  instru- 
ment is  lying  in  the  abdomen.  Hence  in  this  res^Dect  the 
method  of  closing  is  of  little  importance  as  long  as  no  such 
space  is  left  when  the  shanks  are  closed. 

The  blades  are  furnished,  in  all  properly  made  samples,  with 
U-teeth ;  that  is,  the  elevated  ridges  are  blunt-edged,  and 
the  margin  of  the  inner  surface  of  each  blade  is  carefully 
bevelled.     The  object  of  this  aiTangement  is  to  ensure  a  firm 


WELLS     PRESSURE-FORCEPS TAIT  S    PRESSURE-FORCEPS. 


99 


grip  and  the  crushing  of  the  included  tissues  without  any 
cutting.  The  older  instruments  generally  had  Y-teeth,  and 
the  edges  of  the  toothed  siu-face  of  the  blade  were  not  well 
finished,  but  sharp.  This  involved  the  cutting  of  portions  of 
compressed  tissues,  especially  along  the  edges  of  the  blade,  and 
the  consequent  giving  way  of  the  instrument  before  the  pres- 
sure had  been  maintained  for  sufficiently  long  a  period.  As 
the  grip  was,  at  the  same  time,  not  strong,  the  dangers  of 
haemorrhage  were  increased. 

Tait's  Pressure-Forceps. — A  slightly  different  form  of 
pressm'e-forceps  (Fig,  31)  is  figured,  described,  and  recom- 
mended in  Mr.  Lawson  Tait's  Pathology  and  Treatment  of 
Diseases  of  the  Ovaries,  fourth  edition,  p.  258.  I  am  uncertain 
by  whom  it  was  invented,  but,  provided  that  an  instrument 


Fig.  31. — Tait's  Pressure-Forceps. 


be  good,  the  name  of  the  inventor  is  of  secondary  consideration. 
The  outer  surface  of  each  blade  is  exceedingly  convex,  the  curve 
passing  on  to  the  shank  above  the  level  of  the  pivot.  On  the 
other  hand,  the  point  is  not  so  blunt  as  in  the  other  varieties.  In 
this  respect  it  resembles,  to  a  certain  extent,  the  famiHar  Listen's 
artery-forceps,  and  the  inventor  devised  this  form  of  the  point  so 
that  the  loop  of  the  ligatm-e  should  be  the  less  liable  to  catch  in 
the  blades.  The  grip  of  this  forceps  is  very  strong.  As  in  both 
of  the  forms  employed  by  Sir  Spencer  Wells,  the  blades  are 
much  flattened  on  the  plane  of  the  ends  of  the  pivot,  which  is  not 
the  case  in  the  two  oldest  varieties.  In  Tait's  forceps,  however, 
the  pivot  and  the  crossing  of  the  shanks  are  mechanically  the 


100 


INSTRUMENTS   AND   APPLIANCES. 


same  as  in  Koeberle's  and  Pean's,  and  in  Wells'  new  form. 
The  ratchet  has  two  teeth,  as  in  Wells'  new  forceps,  and  closes 
the  shanks  in  the  same  manner.  This  forceps  is  ander  five 
inches  in  length  and  much  lighter  than  Wells'  older  variety, 
hnt  a  little  hea^der  than  the  older  kinds,  as  generally  constructed. 
The  bows  are  mde,  stout,  and  well  bevelled,  and  thus  very 
convenient  for  manipulation. 

This  and  the  last  form  of  forceps  are  valuable  instruments, 
and  one  or  other  will  be  absolutely  needed  by  the  ovariotomist. 

Curved  Pressure  -  Forceps.  —  Eecently  an  excellent 
forceps  has  been  constructed,  on  Wells'  newer  pattern,  and 
with  the  blades  cmwed.  This  forceps  is  a  miniature  of  the 
large  instrument  presently  to  be  described.  It  has  the  advant- 
age of  Ipng  less  in  the  way  than  the  ordinary  form.  After 
seeming  bleeding  vessels  in  the  abdominal  woimd,  mth  the  old 
forceps,  the  surgeon  vail  find  that  the  handles,  being  in  a 
straight  line  with  the  blades,  stick  up  in  the  air,  and  are  apt  to 
be  pushed  by  the  operator's  hand,  or  even  torn  off  from  their 
attachments.  When  the  blades  are  curved  at  an  angle  of  about 
120',  the  handles  "^ill  lie  in  a  more  convenient  position.  I 
believe  that  this  new  form  of  forceps  will  come  into  general  use. 
Nevertheless,  I  do  not  consider  that  it  is  in  any  way  indis- 
pensable. 


Fig.  32. — T-blaued  Pl;J•;s^s^IlE-Foll(•E^s. 


T-bladed  Pressure-Forceps. — This  instrument  (Fig.  32) 
is  also  a  miniatm-e  of  a  larger  forceps  presently  to  be  described. 


T-BLADED    PRESSURE-FORCEPS — PERITOXEUM-HOOK.         101 

Mr.  Thornton  employs  it  for  temporarily  securing  broad  bleed- 
ing surfaces  of  adhesions,  omentum,  etc.  He  also  uses  it  to 
seize  and  compress  the  edges  of  the  divided  uterine  tissues  in 
flap  operations  for  the  removal  of  fibroids.* 

Before  dismissing  the  subject  of  pressure-forceps,  I  must 
observe  that  the  sm-geon  must  never  forget  that  no  form  of  the 
instrument  can  be  expected  to  control  hsemorrhage  by  simple 
momentary  pressm^e.  On  the  contrary,  the  pressm^e  must  be 
continuous  for  five  minutes  at  least.  When,  through  any  cir- 
cmnstance,  a  pressure-forceps  has  to  be  taken  off  directly  after 
its  application  to  a  bleeding  point,  it  must  first  be  made  to 
twist  the  end  of  the  vessel,  or  else  the  vessel  must  be  liga- 
tui-ed. 

Adams'  Peritoneum-Hook. — This  instrument  (Fig.  33) 
consists  of  a  steel  bar  mounted  on  a  handle.  The  extremity 
of  the  bar  bears  two  teeth,  bent  backwards.  When  the  peri- 
toneum is  reached,  it  is  caught  in  the  teeth  and  raised,  the 
instrument  being  held  in  the  left  hand.     A  hole  is  then  made 

- — ->; 

Fig.  33. — Adams'  Peritoneum-Hook. 

in  the  peritoneum  by  means  of  a  scalpel.  Into  this  hole 
the  director  is  introduced. 

Adams'  hook  is  not  indispensable.  When  there  is  no  com- 
plication the  peritoneum  may  be  raised  with  forceps,  or  simply 
scratched  through  by  the  point  of  the  scalpel.  When,  on  the 
other  hand,  the  peritoneum  is  difiicult  to  recognize  or  closely 
adherent  to  the  cyst,  the  hook  is  useless.  It  was  introduced  at 
a  time  when  operators  were  less  certain  of  what  they  might  be 
likely  to  encounter  than  they  are  in  these  days.  Thanks  to 
Sir  Spencer  Wells  and  others  who  have  presented  us,  as  we  may 
say,  with  their  experience  as  pioneers  in  ovariotomy,  we  are 
learning  not  only  what  is  required,  but  also  what  is  superfluous. 

The  hook  is  most  likely  to  be  of  service  in  cases  where,  on 

reaching  the   transversahs   fascia    or   in    di\"iding  it,  there  is 

evidence  of   either  a  very  thin-walled  cyst,  or  of  intestine  or 

*  See  "  Thornton's  T-shaped  Compressing  Forceps"  [British  Medical  Journal, 
vol.  i.,  1881,  p.  55). 


102 


INSTRUMENTS   AND   APPLIANCES. 


ascitic  fluid  lying  between  the  cyst-wall  and  the  peritoneum. 
The  hook  will  then  he  useful  in  dividing  the  peritoneum  safely, 
and  allowing  the  operator  to  see  thoroughly  what  he  is  cutting 
through. 

The  Director. — Stanley's  (often  incorrectly  termed  Key's, 
a  name  originally  given  to  a  strongly  curved  instrument)  is  the 
most  convenient  form  of  director  (Fig.  34).     It  is  well  known 


Fig.  34. — Stanley's  Director. 

to  the  general  surgeon.  It  is  pushed  under  the  peritoneum, 
upwards  and  downwards,  after  a  hole  has  been  made  for  its 
introduction,  and  then  the  peritoneum  is  divided  with  a  scalpel 
or  scissors,  slid  along  the  groove.  On  no  account  must  the 
director  be  employed  to  detach  adherent  peritoneum  from  the 
cyst-wall, 

Ovariotomy-Trocar. — The  ovariotomy-trocar  most  gene- 
rally iised  is  that  known  to  dealers  as  Sir  Spencer  Wells' 
improved  siphon  trocar  (Fig.  35).      It  must  be  ordered  "with 


Fig.  35. — Spexcer  Wells'  OvAuroro-MY-TROfAK. 

india-rubber  tubing  and  siphon  end."  It  is  a  formidable 
looking  instrument  nearly  one  foot  in  length.  Like  other 
implements,  it  is  simple  to  those  who  are  used  to  it,  or  who  have 
often  seen  it  employed ;  but  the  inexperienced  must  study  its 


OVARIOTOMY    TROCAR.  103 

meclianism  thoroughly  before  employing  it  at  an  operation.  The 
entire  instrument,  generally  spoken  of  as  a  "  trocar,"*  really 
consists  of  three  parts.  There  is,  first,  the  cannula,!  a  cyKndrical 
inner  tube  nearly  seven  inches  in  length  and  half  an  inch  in 
diameter.  This  bears  a  curved  and  roughened  thimib-piece 
mounted  on  a  short  stem.  The  end  is  cut  straight,  not  obliquely. 
It  is  not  necessary  that  this  end  should  be  dome-shaped,  as  in  the 
tapping  trocar  presently  to  be  described.  The  second  part  of 
the  instrument  is  the  trocar  proper.  It  is  a  stout  tube,  into 
which  the  cannula  fits  with  great  accuracy.  Its  extremity  is 
cut  obliquely,  like  a  quill-pen,  being  pointed  and  sharp-edged.+ 
The  trocar  is  furnished  with  a  pair  of  spring  hooks.  By 
pressing  the  thumb  and  outer  side  of  the  forefinger  simul- 
taneously on  the  bars  or  handles  of  the  hooks,  they  are  raised 
by  a  mechanical  contrivance,  so  that  the  cyst- wall  can  be  drawn 
up  by  aid  of  a  volsella  above  the  line  of  the  hooks.  On  letting 
go  the  handles,  the  fine  hooks  or  teeth  catch  the  cyst-wall 
firmly,  generally  perforating  it  with  their  points,  which  fit  into 
holes  on  the  trocar. §  At  the  upper  end  of  the  trocar  is  a  slit 
on  the  bayonet- joint  principle  ;  the  stem  of  the  thumb-piece  of 
the  cannula  slides  up  and  down  in  this  slit.  Before  use,  the. 
thumb-piece  is  drawn  up  to  the  top  of  the  slit.  After  the 
cyst  has  been  perforated  and  the  fiuicl  has  begun  to  run  well 
out  of  the  india-rubber  tube,  the  thumb-piece  is  pushed  down 
by  the  thumb,  so  that  the  cannula  projects  beyond  the  sharp 

*  This  term  is  not  of  Greek  but  of  French  origin  :  "  Tkols-qtiarts  otr  Tko- 
CART,  instrument  de  chirurgie  dent  on  se  sert  pour  faire  des  pouctions  :  c'est  un 
poiuijon  d'acier,  monte  sur  un  manche  en  poire,  termine  par  uue  pointe  pyra- 
midale  tiiangulaire  a  bords  ti'anchants,  d'un  surnom,  a  trois  carres"  (Bouillet  : 
Dictionnaire  Universelle  des  Sciences,  des  Lettres,  et  des  Arts).  The  English  form 
"  trocar  "  is  phonetic.     There  is  no  authoritj'  for  spelling  the  word  "  trochar." 

t  This  word  is  generally  spelt  "  canula."  In  Smith's  Dictionary  I  find  "Can- 
nula, £6,  /.  dim  [canna],  a  small,  loiu  reed  :  Appuleius.  Cannula  pulmonis,  the 
loi^idjnpe :  Ccelius  Aurelianus."  The  latter  author  was  a  physician.  It  is 
evident  that  a  real  Latin  medical  word  should  be  spelt  as  it  is  written  in  the 
works  of  recol  Roman  medical  writers. 

X  For  a  good  account  of  the  history  of  this  instrument,  see  "The  Dome  Trocar 
and  Associated  Instruments  in  Paracentesis,  etc.,"  by  Simon  Fitch.  31. D., 
Halifax,  Nova  Scotia  {Britisli  Medical  Journal,  vol  i.,  1887,  p.  263). 

§  In  Mr.  Bryant's  modification  the  hooks  slide  along  the  cannula,  so  that  the 
volsella  is  not  needed. 


104 


INSTRUMENTS   AND   APPLIANCES. 


point  of  the  trocar,  and  thus  preserves  the  tumour  from  further 
wounding.  The  thumb-piece  must  be  made  fast  by  pushing  it 
into  the  side  sht  at  the  end  of  the  longitudinal  slit.  The  third 
part  of  the  entire  instrument  is  the  stout  siphon  end  which 
screws  on,  at  one  end  to  the  trocar,  and  at  the  other  to  a  metal 
ring  at  the  upper  extremity  of  the  gutta-percha  tube.  This 
tube  should  be  about  three  feet  in  length,  and  half  an  inch  in 
diameter. 

Sometimes  the  cannula  is  made  on  Dr.  Fitch's  dome-shaped 
pattern,  to  be  described  under  the  head  of  "Wells'  Tapping 
Trocar. 

The  precise  manner  of  using  this  instrument  will  be 
stated  in  the  chapter  upon  the  operation  of  Ovariotomy. 

Tait's  Trocar. — Mr.  Lawson  Tait  uses  a  trocar  apparatus 
of  a  different  form  (Fig.  36).  It  is  straight  and  about  nine 
inches    in   length.     The   cannula   is   outside,    and  the   spring 


Fig.  36. — Tait's  Ovariotojiy-Trocau. 

hooks,  which  are  fitted  on  to  it,  have  very  long  handles.  The 
end  of  the  trocar  is  flattened  and  terminates  in  a  blunt  point, 
truncated  by  an  elliptical  opening.  On  each  of  the  flattened 
sui'faces,  close  to  the  point,  is  a  wide  oval  hole,  about  three- 
quarters  of  an  inch  in  length.  Inside  the  cannula  moves  a 
small,  stout  lancet-blade,  which  is  fitted  to  a  short  cylinder 
bearing  a  thumb-piece  on  a  stem.  This  stem  slides  along  a 
bayonet- joint  in  the  cannula,  and  when  pushed  down,  the  lancet 
is  thrust  out  of  the  elliptical  opening  at  the  end  of  the  cannula. 
The  cyst  being  perforated,  the  lancet  is  withdi-awn  into  the 
cannula  by  pulling  on  the  thumb-piece,  then  the  cyst-wall 
can  be  drawn  up  into  the  clutches  of  the  hooks,  which  act 
by  a  contrivance  slightly  different  to  that  adapted  to  WeUs' 
trocar.  The  cannula  screws  on  to  a  sijjhon  end.  Mr.  Tait 
claims  for  his  instrument  the  advantages  that,  -being  perfectly 
solid,  it  never  admits  air,  and  ha\ing  no  inside  mechanism,  it 


TAIT's    trocar TAPPING-TROCAR. 


105 


never  gets  out  of  order.  The  form  of  its  point  enables  the 
operator  to  puncture  secondary  cysts  without  any  alteration 
of  the  mechanism  ;  it  is  not  sharp,  and  therefore  can  do  no 
harm.  It  is  an  ingenious  instrument  and,  I  am  informed, 
works  admirably.  It  seems,  however,  to  have  a  good  deal  of 
inside  mechanism.  Mr.  Tait  has  recently,  as  I  understand, 
employed  a  trocar  of  the  simplest  construction.  It  is  a  plain 
cm-ved  tube  with  a  very  blunt  point  and  no  hooks  :  there  are 
two  holes  a  little  above  the  point.  Thus  it  forms  a  trocar  and 
cannula  in  one  piece  of  metal. 

Tapping  -  Trocar. — For  tapping  ovarian  cysts  whenever 
necessary— and  that  should  be  very  seldom— and  for  the  punc- 
ture of  cysts  discovered  deep  in  the  pelvic  cavity,  or  recesses 


YiG.  37.— Well.s'   Tapping-Teocae,  showing  the  Dome-shaped  Exteemity 
OF  the  Inner  Tube,  contrived  by  Dr.  Simon  Fitch. 

of  the  abdomen  dm^ing  the  course  of  an  operation,  a  Wells' 
tapping-trocar  (Fig.  37)  will  be  found  useful.  It  is  a  kind 
of  miniature  ovariotomy-trocar.  The  cannula  and  the  curved 
siphon-end  are  in  one  piece.  The  open  extremity  of  the  can- 
nula is  blunt-edged  and  slightly  narrowed;  close  to  it  are 
three  oval  apertures.  This  contrivance,  invented  by  Dr.  Fitch,* 
prevents  injury  to  deep  structures,  and  at  the  same  time  allows 

*  See  footnote,  p.  103.  Dr.  Fitch  appears  to  liave  been  the  first  to  contrive 
that  the  perforation  should  be  done  by  the  outer  tube,  contrary  to  the  principle 
in  the  old  hydrocele-trocar,  and  also  the  first  to  introduce  a  trocar  with  a  rounded 
extremity  to  its  inner  tube. 


106  INSTRUMENTS    AND    APPLIANCES. 

fluid  to  rim  f^eel3^  The  trocar  is  pointed  aiid  sharp-edged  at 
its  oblique  extremity.  It  bears  a  thumb-piece,  or  (what  I 
think  is  better)  an  opposed  pair;  on  pressing  upon  them  the 
cannula  can  be  worked,  a  small  projection  on  its  surface  sliding 
in  a  bayonet- joint  slit  in  the  upper  extremity  of  the  trocar. 
The  whole  instrument  measures  about  nine  inches,  and  can  be 
fitted  on  to  an  india-rubber  tube.  It  should  always  be  at  hand 
diuing  any  abdominal  section.  When  a  thin-walled  broad- 
ligament  cyst  is  to  be  removed,  this  trocar  is  far  more  handy 
than  the  larger  instrument.  It  removes  the  fluid  contents  of 
the  cyst  vdth.  great  expedition,  and  the  collapsing  cyst-walls  can 
be  taken  up  in  the  operator's  hand,  needing  no  spring  hooks. 

The  intending  purchaser  of  a  sample  of  this  instrument  must 
examine  it,  to  make  sure  that  it  is  of  finished  workmanship, 
and  that  the  metal  of  the  tubing  is  not  too  thin.  If  the  trocar 
is  badly  made,  the  bayonet- joint  will  soon  be  damaged,  as 
the  metal  will  get  bent  around  it  when  the  instrument  is  being 
cleaned  after  use. 

The  Volsella  "  (Fig.  38)  should  be  about  half  a  foot  in 
length,  and  not  longer.     The  handles  and  shanks  are  slender. 


f  iG.  38.— Volsella  for  Ovariotomy. 

Beyond  the  pivot,  the  shanks  are  continued  for  about  two  inches, 
and  are  bent  at  a  wide  curve.  They  terminate  in  strongly- 
bent  prongs  about  a  quarter  of  an  inch  long,  two  on  the  lower 
and  three  on  the  upper  shank,  where  the  middle  prong  is  more 
strongly  curved  than  the  others.  The  forceps  is  held  with  the 
left  thujnb  in  the  upper  bow,  and  the  fore-  or  middle-finger  in 
the  lower ;  in  this  position  then  the  prongs  are  dii-ected  down- 
wards, the  triple  prongs  lying  uppermost. 

This  volseUa  is,  I  consider,  indispensable,  excepting  to  ope- 
rators who  prefer  Bryant's  ovariotomy  trocar  to  other  similar 
*  See  note  on  "Volsella,"  p.   78. 


.  OVARIOTOMY   VOLSELLA — N^LATOn's    VOLSELLA.  107 

instruments.  The  prongs  readily  grasp  the  cyst-wall  close  to 
the  point  where  it  has  just  been  perforated  by  the  trocar.  The 
wall  is  then  pulled  up  under  the  spring  hooks  on  the  trocar, 
which  are  kept  apart  by  the  pressure  of  the  operator's  right 
thumb  and  fingers  (page  103).  This  manoeuvre  is  perfectly 
simple,  and  is  the  best  way  to  prevent  the  collapsing  cyst  from 
slipping  off  the  cannula,  and  to  avoid  escape  of  fluid  into 
the  peritoneal  cavity. 

This  instrument  is  too  delicately  made  for  grasping  uterine 
or  very  firm  solid  ovarian  tumours.  On  the  other  hand,  the 
powerful  volsella  used  in  operations  for  the  removal  of  such 
tumours  is  not  suited  for  application  to  the  soft  walls  of 
ovarian  cysts,  which  they  crush  or  tear,  rather  than  grasp,  to 
the  great  inconvenience  of  the  operator  and  his  assistant. 

Nelaton's  Volsella,  or  Cyst-Forceps  (Fig.  39),  is  a 
strong  and  valuable  instrument  that  should  always  be  at  hand 


Fig.  39. — ]Sr:ELATON's  Volsella. 


in  the  coui-se  of  an  ovariotomy,  but  the  assistant  must  know 
how  to  use  it.  It  measures  nine  inches  in  length.  The  blades 
form  two  stout,  laterally-flattened,  almost  cii^cular  discs.  The 
inner  surface  of  each  blade  is  deeply  grooved,  and  bears  four 
spikes  and  four  holes,  which  fit  similar  holes  and  spikes  on  the 
opposite  blade.  The  blades  have  also  a  large  central  perfora- 
tion. This  aperture  is  bevelled  on  the  outer  aspect  of  the  blade. 
The  object  of  the  perforation  is  to  allow  the  compressed  tissue 
to  bulge  through  it,  so  as  to  form  a  convex  prominence,  which 
acts  like  a  pivot-head,  and  aids  in  making  the  grip  as  firm  as 
possible.  The  bevelling  prevents  the  bulging  tissues  from 
being  cut.  A  similar  arrangement  is  seen  in  tongue-forceps. 
The  shanks  can  be  unfastened  at  the  pivot,  and  they  bear  a 
Matthieu's  catch  opposite  the  handles.  This  instrument  is 
very  useful  for  holding  the  cyst  in  the  stage  of  the  operation 


108  INSTRUMENTS   AND    APPLIANCES. 

between  its  piinctui-e  by  the  trocar  and  the  hgature  of  its 
pedicle.  Two  are  needed  and  should  thus  be  employed,  when 
solid  contents  or  the  septa  within  multiloeular  cysts  are 
broken  up.  After  the  trocar  is  withdrawn,  the  opposite  edges 
of  the  aperture  in  the  cyst-wall  made  by  that  instrument  are 
seized  by  the  operator  by  means  of  the  volsella*  The 
assistant  takes  the  volseUa  in  his  hands,  and  holds  the  cyst-wall 
apart  at  the  trocar- wound ;  then  the  operator  can  enlarge  the 
wound,  and  plunge  his  hand  into  the  cavity  of  the  cyst. 
When  adhesions  are  being  broken  down,  the  cj^st-wall, 
doubled  up  if  possible,  may  convenientl}'  be  held  steady  hj 
the  assistant. 

There  are  certain  precautions  necessary  to  observe  when 
Nelaton's  volsella  is  used.  A  good  broad  piece  of  cyst-wall, 
broader  than  the  blades  themselves,  must  be  seized.  The 
operator  and  assistant  should  ascertain  if  the  cyst- wall  be  firm, 
as  is  the  rule  in  an  ordinary  multiloeular  cyst ;  or  soft,  as  in 
most  malignant  tumours  and  in  cysts  filled  mth  glandular 
material ;  or  brittle,  as  in  some  dermoid  cysts,  or  in  cysts  that 
have  frequently  become  inflamed.  If  soft  or  brittle,  traction 
must  be  effected  with  care  by  the  assistant,  else  whilst  the 
operator  is  groping  in  the  interior  of  the  cyst  one  volsella 
may  tear  away  the  piece  of  wall  which  it  holds,  and  the  cyst 
will  recede  into  the  abdominal  cavity,  into  which  some  of  its 
contents  will  escape.  Again,  if  the  cyst-wall  be  held  too 
tightly  by  the  assistant,  it  may  be  rendered  so  tense  that 
should  it  be  softened  by  some  pathological  change  behind,  the 
operator  will  be  more  likely  to  thrust  his  hand  through  the 
back  of  the  tumour ;  besides,  the  volsella  may  itself  tear 
away  a  large  piece  of  the  tumour  if  carelessly  handled. 
Again,  whilst  the  operator  is  separating  adhesions,  firm  trac- 
tion on  the  cyst -wall  is  dangerous  ;  it  must  be  merely  steadied 
by  the  volsella.  The  assistant  must  not  pull  hard  with  this 
instrument  when  the  tumour  is  coming  out  of  the  abdomen, 
or  the  latter  may  slip   out    suddenly,  allomng   escape  of   in- 

*  Directions  of  this  kind  will  be  more  or  less  repeated  when  I  come  to  the 
details  of  the  operation.  I  consider  that  such  repetition  is  necessary,  as  I  cannot 
very  well  describe  an  instrument  without  noting  how  it  .should  be  employed,  nor 
can  I  describe  an  operation  without  referring  to  the  use  of  each  instrument. 


NELATOn's    VOLSELLA — LARGE    PRESSURE-FORCEPS.  109 

testine  and  omentum,  and  perhaps  lacerating  its  pedicle. 
These  are  no  remote  nor  even  very  unusual  contingencies. 

It  is  therefore  necessary,  when  using  Nelaton's  volsella,  to 
ascertain  the  stoutness  of  the  oyst-wall ;  and  if  it  be  found 
firm,  to  seize  a  good  piece  between  the  blades  of  the  instru- 
ment, and  to  hold  it  tightly,  but  without  violent  traction.  If 
the  wall  be  soft  or  brittle,  it  is  best  to  seize  a  piece  between 
the  blades,  and  to  let  the  instrument  hang  over  the  sides  of 
the  abdomen,  as  it  is  not  safe  for  the  assistant  to  drag  on  its 
handles.  When,  however,  the  walls  are  very  soft,  and,  above 
all,  if  there  be  fear  of  their  tearing  near  the  pedicle,  the  in- 
strument should  be  discarded,  and  a  large  piece  of  cyst-wall 
may  be  held  in  the  assistant's  hands.  This  I  have  often  seen 
performed  with  advantage. 

Dr.  Atlee  employed  a  forceps  designed  by  Dr.  Fitch,  where 
the  blades  formed  a  pair  of  rings,  with  their  opposing  surfaces 
deeply  grooved.  This  instrument  rendered  the  teeth  on  the 
trocar  and  the  simple  volsella  both  unnecessary.* 

Cyst-Forceps:  Large  Pressure-Forceps.— One  of  the 
most  indispensable  instruments  for  the  ovariotomist  is  the  cyst- 
or  large  pressure-forceps.  The  latter  term  is  employed  by  Sir 
Spencer  Wells  (Fig.  40).     It  is  a  large  and  powerful  forceps, 


Fig.  40. — Cyst-Forceps  or  Large  Pressure-Forceps  [straight  blades). 

the  handles  and  shanks  up  to  the  pivot  measuring  together 
over  seven  inches  in  length,  the  blades  and  the  remainder 
of  the  instrument  below  the  pivot  about  two  and  a  half. 
In  the  typical  and  best  form  the  blades  are  bent  at  an  angle 
of    120°   to   the   shanks,    on   the  plane  of   the  extremities  of 

*  Fitch,  loc.  cit.,  p.  103,  footnote. 


110  IXSTRUMEXTS    AND    APPLIANCES. 

the  pivot  (Fig.  41).  On  this  phane  the  blades  are  compara- 
tivelv  flat,  whilst  laterally  they  are  very  blunt-edged,  but  onh" 
slightly  convex  from  above  downwards.  The  point  is  quite 
blunt,  but  not  bulbous.  The  teeth  of  the  blades  are  of  uniform 
size,  large,  blunt  and  oblique.  They  are  fine  examples  of 
U-teeth,  the  signification  of  which  term  has  been  already 
explained.  Owing  to  the  long  leverage  of  the  shanks  and  the 
four  catches,  the  grip  of  the  handles  is  exceedingly  powerful. 
The  shanks  cross  each  other  precisely  as  in  Wells'  new  forceps 
(page  97)  ;  when  the  instrument  is  closed  at  the  fourth  catch 
they  almost  cover  each  other ;  when  closed  at  the  fii'st  there  is 
still  no  gap  between  the  shanks.  It  is  evident  that  a  space  of 
this  kind  would  be  a  more  serious  defect  in  this  than  in  the 
smaller  forceps.  Omentum,  or  even  a  piece  of  intestine,  might 
easily  get  caught  in  the  gap,  and  if  the  operator  raised  the 
handles  without  seeing  the  compHcation,  a  very  gentle  mo^'e- 
ment  would  be  sufficient  to  tear  the  entangled  structure,  owing 
to  the  powerful  leverage  of  the  instrimient.  As  it  is  con- 
structed, such  an  accident  is  impossible.  There  are  four  teeth 
on  the  ratchet,  which  is  placed  half  an  inch  below  the  bows  or 
rings.  These  latter  are  more  than  an  inch  long  in  diameter, 
stout  and  bevelled. 

The  cyst  or  large  pressure-forceps  is  an  instrument  of  the 
liighest  service  to  the  operator  under  many  circumstances.  Should 
part  of  a  large  tumom-  tear  itself  away,  or  rupture  in  the  pro- 
cess of  its  extraction  fi'om  the  abdominal  cavity,  the  haemorrhage 
may  be  very  severe,  and  in  any  case  the  forceps  should  be 
applied  to  the  cyst  below  the  rent  or,  if  possible,  to  the  pedicle. 
There  are  also  cases  where  it  is  advisable  to  secure  the  pedicle 
by  means  of  this  forceps,  and  to  cut  away  the  tumour  before 
ligatiu-e  of  the  pedicle  is  attempted.  This  is  especially  necessary 
when  no  true  pedicle  exists.  The  timioui-  may  have  to  be 
shelled  out  of  its  capsule  or  separated  from  its  adhesions,  a 
process  which  takes  up  much  time.  Then  the  forceps  may  be 
applied  to  the  deepest  part  of  the  capsule  or  tumour,  which  can 
thus  be  safely  grasped.  The  whole,  or  as  much  as  possible,  of 
the  tumour  is  cut  away,  and  the  pedicle  can  be  then  attended 
to ;  on  the  other  hand,  this  instrument  is  not  generall}-  used 
when  a  good  long  pedicle  is  discovered,  without  any  trouble,  as 


CYST-FORCEPS    OR   LARGE    PRESSURE-FORCEPS.  Ill 

the  tapped  cyst  collapses.  Such  a  pedicle  is  thin  and  delicate, 
and  the  blades  of  the  forceps  will  merely  crush  its  tissues  need- 
lessly.* Besides,  it  is  easier  to  apply  the  ligature  before  cutting 
away  the  cyst,  and  this  can  be  done  with  perfect  safety.  If, 
however,  the  cyst  be  bulky  and  loaded  with  glandular  or 
malignant  growths,  and  if  on  extraction  through  the  abdominal 
wound,  its  pedicle  be  found  to  be  thin  and  tender,  the  forceps 
may  conveniently  and  safely  be  fixed  on  the  pedicle,  very  close 
to  its  attachment  to  the  cyst,  or  to  the  base  of  the  cyst  itself. 
The  bulky  tumour,  which  is  then  much  in  the  way,  may  be  cut 
off,  and  the  pedicle  secm-ed  afterwards.  In  separating  adhesions 
to  the  liver  and  omentum  some  operators  apply  it  to  the 
adhesion  and  cut  away  the  cyst,  attending  to  the  possible 
haemorrhage  afterwards.  For  this  purpose,  however,  the  cyst- 
forceps  is  too  large.  Most  operators  find  that  it  is  sufficient  to 
tear  tlirough  the  adhesion  and  secure  the  bleeding  vessels  with 
small  pressm"e-forceps.     This  is  my  own  practice.     In  oophorec- 


FiG.  41. — Large  Peeshure-Forceps.      Varieties  with  T-blades  and  with 
Blades  bent  at  a  Right  and  at  an  Obtuse  Angle. 

tomy  the  cyst-forceps  is  often  needed  in  order  to  keep  the 
tube  and  ovary  steady  whilst  the  ligatm-e  is  being  appHed.  An 
assistant's  hand  is  less  trustworthy  for  the  purpose. 

There  are  two  other  varieties  of  cyst-forceps  in  frequent  use, 
the  straight-bladed  and  the  T-bladed  forceps. 

The  straight-bladed  cyst-forceps  (Fig.  40)  is  simply  a 
magnified  or  enlarged  form  of  Wells'  new  pressm-e-forceps. 
The  U-teeth  of  the  blades  are,  however,  placed  obliquely  in  the 
larger  forceps.  The  T-bladed  cyst-forceps  is  a  large  form  of 
the  T-bladed  pressure-forceps  described  and  figured  at  page  100. 

*  Some  operators,  however,  especially  Dr.  Bantock,  prefer  to  employ  tins 
instrument  even  when  the  simplest  pedicle  is  secured. 


112 


IKSTRUMEXTS   AND    APPLIANCES. 


Wells'    Large    and    Small    Clamp-Forceps. — These 
instruments  (Figs.  42  and  43)  were  once  largely  employed,  but 


Fig.  42. — "Wells    Lauge  Clamp-Forceps. 

are  now  seldom  used,  as  the  large  pressure-forceps  answer  their 
purpose  and  are  of  more  general  application.  Some  operators, 
indeed,  never  use  them.  The  chief  advantage  of  this  kind  of 
clamp-forceps  over  the  large  pressure-forceps  is  the  shortness  of 
the  handles  of  the  former,  which  therefore  do  not  get  in  the  way 
of  the  operator,  and  the  great  length  and  breadth  of  the  blades, 
which  are  suited  for  securing  very  broad  bleeding  surfaces ; 
hence,  it  is  advisable  to  keep  a  large  and  a  small  forceps  of 


Fig.  4.3. — Well.s'  Small  Clamp-Fokcep.s. 

this  kind  in  hand  at  a  general  or  special  hospital,  but  they 
need  not  be  added  to  the  armoury  of  private  operating  practice. 
The  screw  mechanism  on  the  handles  for  fixing  the  blades, 
explained  by  the  woodcuts,  is  neither  so  easy  to  work,  nor  to 
clean,  nor  to  keep  in  order,  as  the  simple  catches  in  the  liandles 
of  the  newer  large  pressure-forceps. 

Pedicle-Needles.  —  These  instniments   are   necessary   for 
transfixing,  and  thus  carrying  the  ligature  through  the  pedicle. 


PEDICLE-NEEDLE.  113 

For  the  purpose  of  securing  the  vessels  in  the  outer  border  of 
the  pedicle  a  stout  cui'ved  suture-needle  is  sufficient ;  it  should 
not  be  sharp-edged,  and  may  be  used  with  or  without  the  aid  of 
a  needle-holder.  An  ordinary  needle  would  involve  clumsy 
and  dangerous  manipidations,  if  employed  for  the  transfixion  of 
the  pedicle. 

Many  diiferent  forms  of  pedicle-needles  have  been  devised. 
The  most  convenient  type  is  a  long  curved  needle  mounted  on  a 
handle  and  bearing  an  eye  near  the  point.  This  "  Liston's 
needle  "  must  be  very  well  known  to  every  surgeon,  as  it  is 
constantly  employed  for  plastic  operations  and  for  any  pro- 
cedure where  ligatures  and  sutures  have  to  be  passed  through 
parts  not  convenient  for  the  play  of  the  fingers  necessary  when 
a  common  suture-needle  is  used. 

The  pedicle-needle  employed  by  the  surgeons  at  the  Samari- 
tan Hospital  (Fig.  44)  is  made  in  several  sizes.     The  best  for 


Fig.  44. — Pedicle-Needle.* 

ordinary  use — that  is,  for  passing  a  ligature  through  a  pedicle  of 
the  common  type — is  six  inches  in  length,  measured  from  hilt  to 
point  along  the  curve,  and  is  mounted  on  a  roughened  ebony 
handle  four  inches  long.  The  eye  should  be  wide  enough  to 
admit  No.  4  China  silk  ligature. t  The  form  of  this  needle 
allows  facility  of  movement  and  command  of  the  point.  The 
operator  must  remember  that  it  may  act  as  a  powerful  lever, 
and  therefore  he  must  hold  the  handle  lightly  as  the  shank  of 
the  needle  passes  through  the  tissues,  else  the  pedicle  may  be 
split.  The  point  must  be  just  sharp  enough  to  push  its  way 
through  a  thick  pedicle,  but  the  edges  of  the  flattened,  curved 
part  of  the  needle  must  be  very  thick  and  blunt.  The  surgeon 
must  see  to  this  when  he  purchases  the  instrument.  Bluntness 
of  the  point  may  bruise  the  tissues  needlessly  and  even  split 

*  Mr.  Thornton  emploj's  a  more  strongly  curved  instrument, 
t  When  the  eye  is  too  narrow-,  threading  in  the  middle  of  an  operation  will  be 
very  troublesome. 

I 


114  INSTRUMENTS    AND    APPLIANCES. 

them.  Sharpness  of  the  edges  near  the  point  may  be  the  cause 
of  large  vessels  being  wounded. 

This  pedicle-needle  must  be  threaded  before  the  operation. 
The  passing  through  of  the  threads  with  the  needle  never 
appears  to  me  to  do  the  least  harm.  On  the  other  hand,  if  the 
needle  be  threaded  after  the  point  has  passed  through  the 
pedicle,  the  process  may  be  troublesome ;  the  shank  of  the 
needle  may  have  to  be  pushed  through  the  pedicle  to  an 
unnecessary  extent,  and  the  surgeon,  pressing  on  the  handle, 
may  cause  the  pedicle  to  be  split  rather  than  simply  perforated. 

A  shorter  and  smaller  pedicle-needle  of  this  kind  should 
always  be  at  hand. 

Sir  Spencer  Wells  advocates  a  larger  and  still  blunter  needle 
(Fig.  45)  with  a  shank  nearly  nine  inches  long,  and  a  very 


Fig.  45. — Wells'  Blunt-ended  PEDicLE-ISrEEDij:. 

stout  roughened  ebony  handle  a  little  shorter  than  in  the  kind 
just  described.  On  account  of  the  length  of  the  shank,  it 
becomes  necessary  that  the  handle  should  be  made  stout  in 
order  that  the  siu-geon  may  control  its  movements  thoroughly. 
The  point  is  exceedingly  blunt,  the  sides  of  the  needle  near  the 
point  still  blunter,  and  the  eye  is  a  large  oval  hole  nearly  a 
quarter  of  an  inch  in  its  long  diameter. 

Long  Pedicle-Needle. — This  instrument  (Fig.  46)  is  not 


Fig.  46. — Long  Pedicle-Xeedle. 

indispensable,  indeed  some  operators  seldom,  if  ever,  employ  it ; 
but  under  one  condition,  at  least,  it  may  prove  of  high  service. 
It  is  a  free  needle — that  is  to  say,  it  is  not  mounted  upon  a 
handle.  In  length  it  measiu-es  over  six  inches,  and  is  made 
of  well-tempered  steel.  In  form  it  is  cyliudiical,  tapering 
gradually  to  a  point  which  is  moderately  sharp.     The  eye  is 


LONG   PEDICLE-NEEDLE NEEDLE-HOLDER.  115 

a  quarter  of  an  incli  long  and  about  one-eighth  of  an  inch 
wide — that  is,  as  wide  as  it  can  be  made  without  weakening 
the  head  of  the  needle  or  rendering  any  bulging  of  its  borders 
necessary ;  this  latter  arrangement  would  cause  the  wound, 
which  the  needle  makes  in  transfixing  the  pedicle,  to  be 
needlessly  wide. 

The  chief  advantage  of  the  long  pedicle-needle  is  its  large 
eye.  Such  an  eye  could  not  be  safely  made  near  the  point  of 
a  handled  pedicle-needle.  The  position  as  well  as  the  size  of 
the  eye  renders  this  needle  very  useful  when  a  broad  pedicle 
requires  a  second  transfixion.  In  describing  the  operation,  I 
shall  explain  how  it  is  necessary,  under  these  circumstances,  to 
re-thread  the  needle  with  one  of  the  ligature  silks,  together 
with  another  silk,  after  the  first  transfixion.  Threading  needles 
in  the  midst  of  an  operation  is  a  troublesome  proceeding, 
especially  when,  as  in  this  case,  the  threading  must  be  done  by 
the  operator  or  his  senior  assistant,  the  position  of  the  needle 
at  the  time  preventing  anybody  else  from  doing  that  service. 
The  difficulty  is  much  lessened  by  the  size  of  the  eye  of  this 
needle.  With  an  ordinary  curved  and  handled  needle  this 
re-threading  process  is  very  troublesome. 

The  Needle-holder  (Fig.  47)  should  be  stout,  as  it  has  to 


Fig.  47. — Needle-holder. 

be  employed  in  passing  needles  through  the  integument  in  the 
abdominal  walls.  The  shank  should  be  about  five  inches  long, 
between  the  bows  and  the  pivot.  The  blades  are  exceedingly 
stout,  short  and  curved,  and  terminate  in  a  very  blunt  nozzle. 
Their  inner  surfaces  are  roughened.  The  instrument  should  be 
held  so  that  when  the  thumb  lies  in  the  upper  bow,  the  blades, 
holding  the  needle,  tm^n  towards  the  part  to  be  transfixed. 
For  general  use,  this  instrument  is  excellent. 


116  INSTRUMENTS    AND    APPLIANCES. 

The    Needles. — The   needles    employed    by    ovariotomists 
are  generally  stout  and  straight  (Fig.  48).    They  are  triangular, 


Fig.  48. — Needle  for  Oyaeioto.my. 

with  sharp  angles,  near  the  point.  An  ordinary  curved  suture- 
needle,  such  as  is  carried  in  a  surgeon's  pocket-case,  is  best  for 
the  purpose  of  passing  a  silk  ligature  through  the  outer  border 
of  the  pedicle  in  order  to  secui^e  the  ovarian  vessels. 

Hagedorn's  Needle  and  Needle-holder. — Dr.Hagedorn, 
of  Magdeburg,  is  the  inventor  of  a  special  form  of  needle  much 
used  by  British  and  Continental  surgeons,  particularly  for  plastic 
operations.  It  is  very  serviceable  in  operations  for  ruptured 
perineum,  and  in  the  application  of  a  suture  to  the  edges  of  the 
stum  J)  of  the  pedicle  of  the  uterus  after  the  removal  of  a  fibroid 
tumour,  as  will  be  described  in  the  chapter  on  Hysterectomy. 
In  sewing  up  wounds  of  intestine,  damaged  during  the  separa- 
tion of  adhesions  in  ovariotomy  and  hysterectomy  it  is  in  some 
respects  superior  to  the  ordinary  needle. 

The  kind  of  needle  in  general  use  has  a  stem,  the  section  of 
which  forms  either  a  circle  or  an  oval.  It  is  flattened  at  the  inner 
side  of  its  cm-ve,  so  as  to  present  a  broad  double  edge,  which 
is  transverse  to  the  curve  and  terminates  in  a  point.  Hence, 
when  used  for  the  introduction  of  a  suture  by  the  side  of  a 
wound,  it  makes  a  punctm-e,  or  rather,  a  small  vei-tical  incision, 
parallel  mth  the  direction  of  the  wound.  On  tying  the  suture, 
the  inner  margin  of  this  incision  is  dragged  inwards  towards  the 
wound  ;  so  that  an  eUiptical,  or  even  triangular,  gap  is  formed 
at  the  site  of  the  pimctm-e,  which  may  be  slow  to  heal  (Fig. 
50,  «,  h).  A  small  fistula  or  abscess  may  form  thi'ough  the 
nature  of  the  punctm-e.  The  point  of  the  old  kind  of  needle, 
flattened  on  its  concave  side,  is  weak  and  apt  to  deviate  from  its 
intended  direction  in  tough  or  hardened  tissues.  In  short,  this 
older  kind  of  needle  has  at  least  two  serious  disadvantages, 
especially  when  employed  for  plastic  operations.  In  such  pro- 
ceedings it  is  particularly  important  that  the  needle  should 
run  easily  through  the  tough  integument,  and  that  the  wound 
should  heal  as  quickl}'  as  possible,  the  punctui-es  being  of  such 


HAGEDORN  S  NEEDLE  AND  NEEDLE-HOLDER. 


J17 


a  nature  as  to  offer  no  chance  of  any  complication  interfering 
with  union  by  first  intention.  The  presence  of  fistulous  tracks 
and  small  abscesses  near  the  wound  is,  of  necessity,  liable  to 
defeat  the  object  of  any  plastic  operation. 

The  stem  of  Dr.  Hagedorn's  needle  forms  an  oblong  parallelo- 
gram on  section.  It  is  of  equal  width  and  thickness  thi'oughout 
its  entii'e  length,  and  is  curved  on  its  axis,  with  its  short  cutting 
edge  on  its  convex  side  near  the  point.  This  edge  is  about  three 
times  the  width  of  the  needle.  The  curve  of  the  needle  forms 
a  semi-circle. 

Being  curved  on  the  edge,  this  needle  is  more  resistant  than 
the  older  form,  and  the  point  follows,  without  deviation,  the 
intended  direction  of  the  puncture.     The  eye  perforates  the  flat 


STRAIGHT 


Fig.  49. — Hagedorn's  Needles  [natural  size). 

side,  so  that  it  can  be  made  larger  and  more  tapering  at  the  ter- 
minal end,  in  consequence  of  which  even  a  stout  double  thread 
will  pass  without  difficulty  through  the  punctiu-e.  The  needle 
is  of  equal  thickness  throughout.  Hence,  when  under  different 
circumstances  it  may  be  thought  advisable  to  grasp  the  needle 
in  the  holder  at  different  parts  of  its  length,  so  as  to  facihtate 
its  passage  through  the  tissues,  this  may  be  done  without  any 
risk  of  breaking  or  bending.  The  cutting  edge  of  Hagedorn's 
needle  is  on  the  convex  side,  and  is  as  short  as  possible,  consistent 
with  efficiency.  It  cannot  be  injui-ed  or  blunted  by  the  needle- 
holder,  and  may  readily  be  sharpened  when  required.  Owing 
to  the  form  of  the  needle,  the  incision  which  it  makes  is  not 
vertical,  but  horizontal  as  in  a  button-hole,  and,  therefore,  at 


118 


INSTRUMENTS   AND    APPLIANCES. 


a  right  angle  to  the  edge  of  the  wound,  so  that  the  two  edges 
of  the  stitch- wound,  on  tjdng  the  sutui-e,  are  di-awn  into  close 
apposition  (Fig.  50).  These  needles  cause  less  injuiy  to  the 
tissues  than  the  older  form,  which  is  of  high  importance,  especiall}'- 
in  sutures  of  nerves  and  tendons,  as  well  as  in  plastic  operations. 
As  there  are  operations  where  a  shallow- curved,  or  even  a 
straight  needle,  is  required,  five  different  forms  (see  Fig.  49)  are 
made.  In  Fig.  49,  Nos.  6  and  10  (the  smallest)  are  represented. 
Dr.  Hagedorn  has  contrived  a  needle,  with  a  round  point,  for 
intestinal  sutures.  A  thinner  form  of  needle,  useful  in  plastic 
operations  on  the  female  organs,  has  been  invented. 


Fig.  50. — DiAiniAM  showixg  Effkcts  of  Sutuke  ox  Woitxp  made  by 
(/I,  0)  Okdixary  and  {c,  d)  Hagedorx's  Needles. 

Dr.  Hagedorn  has  also  invented  a  needle-holder  which  can 
grasp  the  needle  firmly  without  any  risk  of  breaking  it.  The 
needle  can  he  seized  or  disengaged  A\dth  equal  readiness ;  and 
its  point,  after  having  passed  through  the  tissues,  can  be  taken 
hold  of  without  injury  to  itself  or  to  the  siuTOunding  soft  parts, 
being  guarded  by  the  jaws  of  the  needle-holder. 

The  needle-holder  (Fig.  51)  consists  of  a  steel  rod,  ending  in 
a  handle,  upon  which  a  similar  shorter  rod  is  made  to  glide  up 
and  do^-n.  Both  rods  form,  at  a  right  angle  to  their  anterior 
termination,  the  jaw,  which  is  lined  with  copper.  The  up-and- 
down  movement  of  the  rods  is  effected  by  a  lever  handle,  held 
in  position  l)y  a  moveable  screw.  A  ratchet  on  the  lower  part 
of  the  handle  serves  for  fixing  the  needle.     When  the  handle  is 


hagedorn's  needle-holder.  119 

fixed  to  the  first  tooth  on  the  ratchet,  a  stout  needle  can  be  held 
in  the  jaw;  the  second  and  third  teeth  are  intended  for  fixing 
the  handle  when  finer  needles  are  used.  A  slight  pressure  with 
the  little  finger  on  the  ratchet  will  easily  release  the  stop,  and 
set  the  needle  free.  In  using  it,  the  needle-holder  is  held  in 
such  a  position  that  the  little  finger  is  near  the  ratchet,  ready 
for  releasing  its  hold  by  slightly  pressing  against  it.  Care  must 
be  taken  that  the  needle  is  placed  in  the  longest  diameter  of  the 
jaw,  with  the  inner  curve  close  to  the  stem  of  the  fixed  rod. 
Only  when  the  needle  has  been  grasj)ed  in  this  manner  will  its 
perfectly  firm  position  be  secured.  The  surgeon  must  never 
attempt  to  pass  a  needle  through  tissues,  by  the  aid  of  this 
holder,  without  having  fixed  the  lever  handle  in  the  ratchet. 


Pig.  51. — Hagedokn's  jSTeeule-holdek. 

Otherwise  the  handle  will  press  inconveniently  on  the  palm 
of  his  hand,  and  the  needle  will  probably  slip  out,  or  become 
deflected  from  its  right  coixrse. 

Two  varieties  of  the  holder  are  especially  made  for  operations 
on  women.  One  kind  has  a  rectangular,  and  the  other  an 
oblique  jaw. 

Hagedorn's  needle-holder  is  easy  to  work  after  a  little 
practice.  If  the  surgeon  attempts  to  use  it  in  the  course  of  an 
operation  without  having  mastered  its  mechanism,  which  is  no 
difiicult  task,  he  may  get  into  difiiculties,  and  throw  unfair 
discredit  on  the  instrument.  It  cannot  be  denied  that  new 
inventions  are  sometimes  discredited  in  this  manner. 

Sutures. — These  may  be  either  of  silk,  composed  of 
No.  2  Chinese  twist,  or  else  of  silkworm-gut.  They  should  be 
cut  about  a  foot  and  a  half  long.     If  too  short,  they  are  incon- 


120  INSTRUMENTS    AND    APPLIANCES. 

venient  for  the  assistant  to  hold  firmly,  whilst  the  surgeon  is 
sponging  the  peritoneal  cavity  previous  to  closing  the  wound. 

Each  end  of  a  suture  is  thi-eaded  on  to  a  needle  of  the  kind 
described  at  page  116.  A  set  of  six  or  eight  pairs  of  needles 
are  thus  treated  before  operation,  and  fastened  on  to  a  striiD  of 
carbolic  or  thymol  gauze,  each  pair  being  held  close  together, 
and  then  made  to  transfix  the  gauze.  The  strip  of  gauze  is 
then  rolled  up,  and  placed  in  a  convenient  position  in  the  tray. 

Silkworm-Gut. — This  material  has  been  much  used,  and 
greatly  recommended  by  Dr.  Bantock  and  other  operators. 
I  believe  that  it  is  the  best  material  for  closing  the  abdominal 
wound,  being  easy  to  introduce,  and  particularly  easy  to 
remove.  I  do  not  say  that  if  left  in  the  tissues  it  can  never 
excite  irritation,  nor  cause  abscess.  It  may  do  both.  Like  any 
other  kind  of  sutm-e,  however,  it  must  not  be  left  in  the  tissues. 
Being  readily  removed,  there  is  no  excuse  for  leaving  it  in  the 
tissues.  Silkworm  gut  is  also  valuable  for  plastic  operations. 
For  hgature  and  sutm'es  within  the  peritoneal  cavity,  silk 
must  be  employed. 

Silkworm-gut,  or  fil  de  Florence,  is  thus  prepared.  The 
silkworms,  when  full-grown  and  about  to  spin,  are  steeped  in 
vinegar.  This  makes  their  bodies  soft,  and  converts  the  fluid  in 
the  silk-glands  into  a  pulpy  mass.  After  soaking  in  ^dnegar 
for  two  hours,  the  skins  are  removed  fi-om  the  worms,  and  the 
silk-glands  are  extracted.  The  glands  are  then  rolled  between 
the  finger  and  thumb,  stretched  to  the  necessary  length  and 
thickness,  and  fixed  till  dry.* 

This  material  is  much  used  by  anglers,  ^^len  employed  by 
the  surgeon,  the  red-stained  samples  are  the  best.  It  must  be 
soaked  in  water,  pure,  or  carboHzed  for  at  least  ten  minutes  or 
more  before  use.  If  not  sufficiently  soaked,  it  remains  stiff  and 
slippery,  and  is  very  apt  to  slip  out  of  the  needle-hole  when  it 
is  being  passed  through  the  abdominal  wound.  This  causes  the 
operator  much  trouble,  as  I  know  from  the  experience  of  one 
of  my  o-uTi  cases,  where  the  gut  had  not  been  properly  prej)ared 
by  the  nurse.     It  is  as  smooth  as  spun-glass  or  metallic  suture, 

*  The  Colonics,  1878.  Dr.  Bantock  quotes  the  original  in  "First  Series  of 
Twenty-five  Cases  of  Completed  Ovariotomy  "  (British  Mcdiad  Journal,  vol.  i., 
1879,  p.  770). 


SILKWORM-GUT.  121 

and  not  being  composed  of  strands  or  fibres,  it  cannot  lodge 
fluids  or  minute  particles  of  solid  organic  matter,  like  silk 
sutures.  Being  very  pliable,  it  flies  apart  wben  cut  on  one 
side  of  the  knot.  This  property  greatly  facilitates  the  removal 
of  the  sutures  from  the  abdominal  wound. 

Care  must  be  taken,  after  the  comf)lete  set  of  silkworm-gut 
sutures  have  been  introduced  into  the  abdominal  wound,  that 
they  are  not  jerked  out  of  the  assistant's  hands  whilst  the 
operator  is  introducing  or  withdrawing  the  sponges  employed 
for  cleansing  the  peritoneum.  This  may  happen,  as  the  gut 
becomes  slippery  when  wet.  To  avoid  the  accident,  the  ends  of 
the  gut  threads  should  be  collected  on  each  side  and  held 
together  by  compression-forceps.  As  the  cut  ends  of  the  gut 
become  stiff  when  it  dries,  the  operator  must  be  careful  that 
they  do  not  turn  directly  upwards  or  downwards,  so  as  to  sink 
between  the  cut  surfaces  of  integument  into  the  wound.  The 
cut  end  need  never  be  over  a  quarter  of  an  inch  in  length. 


122 


CHAPTEE  lY. 

mSTRUMENTS   AND    APPLIANCES 

(Continued). 

Instruments  used  in  Hysterectomy. — I  shall  now 
proceed  to  describe  certain  instruments  which  are  required  for 
hysterectomy.  They  should  be  at  hand  whenever  the  surgeon 
operates  in  a  case  of  doubtful  pelvic  tumour,  and  particularly 
when  oophorectomy  for  the  cure  of  uterine  fibroid  is  contem- 
plated. It  may  very  probably  be  found  that  the  pedicle  of  one 
or  both  appendages  cannot  be  safely  secured  and  that  haemor- 
rhage can  only  be  checked  by  amputation  of  the  uterus  above 
the  cervix. 

Koeberle's  Serre-Nceud. — This  instrument  is  sometimes 
termed  an  ecraseur  and  sometimes  a  wire  clamp,  but  serre-noeud 
appears  to  be  the  name  by  which  it  is  generally  known.  I 
therefore  retain  that  name,  but  to  all  intents  and  purposes  it  is  a 
clamp,  and  was  originally  used  as  such  by  Professor  Koeberle, 
of  Strasburg,  in  ovariotomy.  In  his  Manuel  OiJeratoire  de 
r  Ovariotomie  (1870),  with  notes  by  Dr.  Taule,  he  states  that  it 
was  then  his  custom  to  secure  the  pedicle  of  an  ovarian  tumour 
with  this  serre-noeud,  which  he  considered  as  superior  to  the 
clamps  then  in  use  ;  it  could  be  apphed  in  all  cases,  and  this 
fact  alone  made  the  instrument  incontestably  superior  to  any 
other.  By  this  assertion,  he  signified  that  the  wire  of  the  serre- 
noeud  could  be  apphed  to  a  very  broad,  short  pedicle,  or  even 
around  the  deepest  part  of  a  cyst  when  no  pedicle  existed ;  this 
could  not  be  done  satisfactorily  by  Wells'  or  Hutchinson's 
instruments.  In  those  days  the  clamp  was  always  preferred, 
and  therefore  always  employed  excepting  when  the  pedicle  was 
too  short  to  allow  of  its  use.     Koeberle's  instrument  met  these 


KOEBERLE  S    SERRE-NCEUD. 


123 


exceptional  cases,  and  therefore  was  perhaps  the  best  according 
to  the  ideas  then  current.  Our  practice  with  regard  to  securing 
the  ovarian  pedicle  has  entirely  changed  since  1870,  nor,  indeed, 
was  the  serre-nceud  ever  popular  amongst  British  ovariotomists. 
It  is  in  supra-vaginal  hysterectomy  and  allied  operations  that 
this  instrument  has  since  proved  to  he  of  high  value. 

Fig.  52  represents  the  variety  of  Koeberle's  serre-noeud  which 
is  employed  by  Dr.  Bantock.  It  consists  of  a  steel  cylinder, 
which  should  measure  about  four  inches  in  length,  and  is  hollowed 
to  allow  a  long  screw  to  revolve  within  it.  At  one  extremity 
it  is  flattened  and  bridged  for  the  passage  of  a  loop  of  vsdre. 
This  extremity  must  be  well  finished,  as  it  comes  close  in  con- 
tact with  the  stump  of  the  uterine  pedicle.     At  the  opposite 


Fig.  52. — Koeberliii'.s  Serre-jSTceud. 


extremity  is  a  contrivance  whereby  a  key  or  handle  may  be 
fitted  on  so  as  to  work  the  screw.  A  button,  with  a  short  shank 
constructed  so  that  it  moves  along  the  thread  of  the  screw,  slides 
along  a  slit  on  the  upper  surface  of  the  cylinder.  Just  below 
the  handle"  the  instrument  is  furnished  with  a  pair  of  wings, 
which  are  very  convenient  for  the  purpose  of  steadying  it  when 
the  wire  is  being  tightened. 

When  the  serre-noeud  is  required  a  stout  piece  of  soft,  flexible 
iron  wire,  about  one  foot  long  and  bearing  at  one  end  a  small 
ready-prepared  loop,  is  taken,  and  the  loop  is  slipped  over  the 
button,  whilst  the  other  end  of  the  wire  is  passed  under  the 
bridge  at  the  flattened  extremity  of  the  instrument  and  then 
round  the  pedicle.  When  this  has  been  done — and  more  will 
be  said  about  this  subject  presently — the  end  of  the  wire  is  passed 


124  INSTRUMENTS    AND    APPLIANCES. 

back  through  the  hole  and  twisted  round  the  shank  of  the 
button.  Care  must  be  taken  to  keep  the  button  uppermost. 
Special  pliers  or  nippers  are  generally  necessary  for  pulling  the 
loop  tight  previous  to  coiling  it  round  the  button.  Then,  by 
means  of  the  key,  the  loop  of  wii'e  is  di'a^m  as  tight  as  the 
operator  may  deem  desirable. 

Koeberle's  serre-nceud  is  far  superior  to  Cintrat's,  as  it  allows 
the  wii'e  to  be  tightened  at  any  moment  when  required,  whilst, 
when  the  latter  instrument  is  used,  the  wire  is  twisted  once  for 
good.  The  serre-nceud  is  then  removed.  It  fi-equently  happens 
that  the  wire  very  soon  requires  tightening,  so  that  after  the 
use  of  Cintrat's  serre-noeud  the  wire,  should  this  accident  occui', 
wall  have  to  be  readjusted.  The  serre-nceud  itself  may  not  be 
at  hand  at  the  critical  moment. 

Pedicle-Pins. — For  the  purpose  of  keeping  the  uterine 
pedicle  from   shpping  back  into  the  peritoneal  cavity,  special 


B 

Fig.  53. — Pedicle-Pins  foe  Hysterectomy. 

pins  have  been  devised.  The  pin  should  be  over  four  inches  in 
length,  stout,  and  made  of  steel.  The  point  must  be  sharp,  as 
it  has  to  penetrate  very  tough  tissues.  The  handle  is  oval  and 
flattened,  and  rough  on  one  side  so  as  not  to  slip  from  between 
the  finger  and  thumb  when  it  is  held.  The  smooth  side  must 
be  kept  downwards  towards  the  integuments.  After  transfixion 
the  point  is  shpped  into  a  channel  in  a  metal  guard,  shaped 
precisely  like  the  handle. 

Two  of  these  pins  are  generally  needed.  A  great  many 
precautions  will  be  required  during  their  use,  and  these  will  be 
noted  in  the  chapter  on  Hysterectomy  for  Uterine  Fibroids,  and 
explained  by  a  di'awing. 

Drainage. — I  shall  now  describe  the  appliances  which  are 
necessary  for  the  purpose. 


DRAINAGE-TUBES.  125 

Drainage-Tubes.* — These  contrivances  are  widely  used 
by  some  specialists,  and  but  little  employed  by  others.  They 
are,  however,  never  entirely  rejected.  They  consist  in  drainage- 
tubes,  a  glass  s^T-'inge  with  india-rubber  tubing,  and  a  square  of 
india-rubber  sheeting. 

GlasH  Drainage-Tubes. — Grlass  instruments  are  always  em- 
ployed at  first  when  drainage  is  resorted  to  in  abdominal 
operations,  excepting  in  some  cases  where  a  shallow  or  very 
irregular  cavity  requires  drainage  or  where  lumbar  incisions  are 
made,  such  as  in  removal  or  incision  of  a  diseased  kidney. 
India-rubber  tubing  is,  owing  to  its  physical  characters,  unsuited 
for  drainage  through  an  abdominal  wound.  It  is  Douglas's 
pouch,  or,  in  rare  instances,  the  depths  of  the  lumbar  region, 
that  has  to  be  drained,  and  for  such  a  purpose  a  firm  material 
is  necessary,  for  the  intestines  and  the  uterus  will  probably  press 
against  the  tube.  Grlass  is  particularly  suited  for  the  purpose, 
and  as  the  patient  hes  quiet  on  her  back,  there  is  no  internal  nor 
external  force  that  can  break  a  stout  glass  drainage-tube. 
During  attacks  of  violent  delirium  or  nervous  agitation,  when 
the  patient  tosses  about,  throws  herself  on  her  side,  or  even 
turns  completely  round  or  jumps  out  of  bed,  the  tube  may 
become  displaced  or  may  fall  out,  but  it  cannot  readily  be 
broken  within  the  abdominal  cavity.  These  tubes  are  made  of 
three  or  four  different  lengths. 

KoeherWs  Drainage- Tube  (Fig.  54)  tapers  to  a  point,  which  is 
blunt  and  closed,  and  the  sides  are  perforated  for  more  than 


Fig.  54. — Koeberli^'.s  Drainage-Tube. 

two  inches  above  the  extremity.  The  upper  orifice  is  everted. 
The  rounded  end  was  probably  designed  to  He  against  the 
peritoneum  in  Douglas's  pouch  without  hurting  it,  and  the 
holes  in  the  side  of  the  tube  let  in  fluid  as  it  coUeets  in  the 
peritoneal  cavity. 

*  For  the  study  of  this  question,  as  treated  by  its  special  exponents,  I  refer  the 
reader  to  Dr.  Keith's  works  and  to  Dr.  Bantock  On  Drainage  in  Ovariotomy. 


126  INSTRUMENTS    AND    APPLIANCES. 

Dr.  KeiWs  Drainage- Tube  (Fig.  55)  is  preferable  to  the  form 
just  described.  It  does  not  taper  to  a  point,  but  its  lower  orifice 
is  nearly  as  wide  as  its  general  calibre,  being  very  slightly 
inverted  so  that  ihQ  edge  should  not  be  sharp  enough  to  irritate 
the  peritoneum.  The  perforations  do  not  extend  for  more  tha,n 
a  little  over  an  inch  above  the  extremity.  The  mouth  or 
upper  orifice  is  not  everted,  but  half  an  inch  below  it  is  a  broad 
rim,  which  not  only  prevents  the  tube  from  slipping  into  the 
abdominal  cavity,  but  is  also  extremely  convenient  for  the 
application  of  the  india-rubber  sheeting. 

This  tube  is  constructed  according  to  sound  principles.  The 
fluid  which  has  to  be  removed  tends  to  collect  at  the  bottom  of 
Douglas's  pouch,  and  the  tube  accordingly  is  open  at  its  lowest 
part,  which  is  pressed  into  that  pouch.  The  perforations 
counteract  atmospheric  pressure  above  sufficiently  to  allow  the 
fluid  to  rise  as  it  collects  in  the  pouch,  whilst  Koeberle's  tube  is 


Fig.  55. — Keith's  Dkainage-Tube. 

perforated  too  high  up,  so  as  to  interfere  with  the  retention  of 
fluid  in  and  around  the  orifice  of  the  tube.  Hence,  when  the 
syi'inge  is  used,  the  fluid  is  more  at  hand  and  easier  to  with- 
draw when  Keith's  tube  is  employed. 

Primary  Drainage. — Before  the  tube  is  introduced  in  the 
course  of  an  operation,  Douglas's  pouch  must  be  well  cleaned 
with  small  sponges  mounted  on  holders,  if  not  flushed  out  with 
warm  water  as  well.  This  must  be  done  after  the  sutm^es  have 
been  inserted  into  the  tissues  of  the  abdominal  wall.  In  the 
chapters  on  Ovariotomy  the  manner  of  securing  the  ends  of  the 
sutures,  lest  they  should  be  dragged  out  of  their  tracks  during 
the  sponging  process,  will  be  described.  The  operator  must 
pass  the  tube  into  Douglas's  pouch  with  his  right  hand,  keepino- 
the  intestines  back  with  his  left.  The  tube  should  be  j)assed 
between  the  two  lowest  sutm-es.  It  must  be  of  such  a  length 
that  when  its  extremity  touches  the  bottom  of  Douglas's  j)ouch, 
the  rim  or  shoulder  near  the  upper  orifice  lies  nearly  level  with 


USE    OF    THE    DRAINAGE-TUBE.  127 

the  abdominal  wound,  and  not  high  above  it.  In  testing  this 
question  of  measurement  the  operator  must  make  allowance  for 
the  condition  of  the  abdominal  walls  at  the  moment  of  intro- 
duction, as  they  may  be  distended  above  their  usual  level.  For 
at  this  late  stage  of  the  operation  the  patient  is  not  always 
thoroughly  under  the  influence  of  the  ansesthetic,  the  adminis- 
trator being  apt  to  relax  his  exertions,  which,  however,  he 
should  be  strictly  forbidden  to  do,  The  tube  must  be  kept 
perfectly  straight. 

The  sutures  are  then  tied  by  the  operator,  whilst  the  assistant 
keeps  his  left  forefinger  on  the  orifice  of  the  tube,  pressing  it 
very  gently.  Without  this  precaution,  he  or  the  operator  may 
inadvertently  puH  the  tube  out  of  Douglas's  pouch  whilst 
sponging  the  edges  of  the  wound  or  tying  the  sutures.  If 
this  occur  and  be  not  noticed,  a  coil  of  intestine  may  get  be- 
tween the  end  of  the  tube  and  the  deepest  part  of  Douglas's 
pouch.  The  tube  will  thus  be  in  a  position  unsuited  for  perfect 
drainage. 

The  sutures  having  been  tied  and  cut  short,  a  piece  of  india- 
rubber  cloth  (presently  to  be  described),  perforated  in  the 
centre,  is  slipped  over  the  tube,  so  that  the  hole  in  the  sheet- 
ing embraces  the  tube  tightly  immediately  below  the  rim. 
This  cloth  is  a  clean  and  valuable  appliance,  superior  to  any 
other  which  I  have  seen  employed  for  the  same  piu"pose.  The 
cloth  is  thin  but  strong,  and  the  physical  characters  of  the 
material  allow  it  to  be  held  well  on  to  the  tube,  and  prevent 
the  wide  escape  of  fluid  issuing  from  the  mouth  of  the  tube. 

The  four  corners  of  the  sheeting  are  then  folded  over  the 
orifice  of  the  tube,  after  the  latter  has  been  covered  by  a  smaU 
conical  sponge.  A  few  pieces  of  absorbent  gauze,  folded  six 
or  eight  times,  and  cut  about  three  inches  square,  are  placed 
on  each  side  of,  and  above  and  below,  the  protruding  tube. 
Then  the  lower  part  of  the  abdominal  binder  is  pinned  over 
the  tube  and  its  covering.  Once  more  the  assistant  must  see 
that  the  tube  is  not  dragged  up  in  the  coui-se  of  these  mani- 
pulations. 

In  order  to  empty  the  tube,  a  common  glass  syringe  with 
a  piece  of  india-rubber  tubing  is  sufficient.  The  tubing  must 
be  about    an   inch   longer  than  the  drainage-tube,  and  much 


128  INSTRUMENTS    AND    APPLIANCES. 

narrower  in  calibre,  else  it  may  pull  the  tube  up  wben  being- 
retracted.  Care  must  be  taken  lest  the  tubing  split  whilst 
being  slipped  over  the  broad  part  of  the  nozzle  of  the  syringe. 
The  tubing  being  passed  to  the  bottom  of  the  glass  tube,  the 
fluid  is  drawn  gently  into  the  syringe.  When  antiseptic  in- 
jections are  employed  after  the  withdrawal  of  all  the  fluid 
that  will  come  away,  a  syringeful  must  be  injected,  and  a 
little  less  withdrawn  a  few  seconds  later.  The  operator  should 
clean  the  tubing  himself  after  use. 

Secondary  Drainage. — Attempts  to  establish  drainage  after 
the  close  of  the  operation,  when  bad  symptoms  have  appeared, 
are  not  attended  with  such  good  results  as  in  the  case  of 
primary  drainage.  The  intestines  and  omentura  often  become 
matted  together,  so  that  a  collection  of  noxious  fluid  cannot 
always  be  reached.  Secondary  di-ainage  is  very  satisfactory 
when  pus  or  serum  lies  close  under  the  wound  or  oozes  through 
its  lips.  In  this  case,  however,  a  rubber  and  not  a  glass  tube  is 
generally  the  more  suitable. 

India-rubber  Cloth  for  Drainage-Tube. — I  have  just 
alluded  to  this  appliance.  Whenever  the  drainage-tube  is 
employed,  it  is  advisable  to  protect  the  parts  and  the  dress- 
ings b}'"  means  of  a  piece  of  india-rubber  cloth,  about  one  foot 
and  a  haK  square.  A  small  hole  is  cut  in  the  centre  of  the 
cloth.  After  the  tube  has  been  inserted  into  the  wound,  the 
edge  of  the  hole  in  the  cloth  is  slipped  over  the  rim 
below  its  orifice,  so  that  the  cloth  can  be  made  to  grip 
the  neck  of  the  tube,  which,  through  its  elasticity,  it  can  do 
in  a  very  effectual  manner,  provided  that  the  hole  has  not 
been  made  too  large.  If  properly  adjusted  in  the  manner 
already  described,  the  cloth  will  catch  any  fluid  which  may 
escape  in  such  quantities  as  to  soak  through  the  sponge  or 
other  covering  placed  over  the  orifice  of  the  tube.  At  each 
dressing  the  surgeon  has  merely  to  turn  down  the  corners  of 
the  cloth,  and  the  tube  will  at  once  become  accessible. 

The  chief  feature  in  the  proper  application  of  the  india- 
rubber  cloth  is  the  size  of  the  hole,  for  if  it  be  too  large,  its 
edges  will  not  grasp  the  neck  of  the  tube  with  sufficient  firm- 
ness, and  a  space  may  be  left  through  which  fluid  will  run 
under  the  level  of  the  cloth.     After  appHcation,  the  advantage 


INDIA-RUBBER    CLOTH   AND    DRAINAGE    TUBES.  129 

of  the  cloth  will  be  evident.  It  is  light,  readily  folded,  and 
perfectly  waterproof.  India-rubber  tissue  is  too  thin  and  not 
sufficiently  elastic,  whilst  mackintosh  is  too  heavy  and  is 
otherwise  objectionable  for  the  purpose  which  india-rubber 
cloth  fulfils  so  well. 

India-rubber  Drainage-Tubes. — These  may  be  required 
when  a  shallow  cavity  needs  drainage,  or  when  a  collapsed 
sac,  or  natural  space  which  has  been  opened  up,  hes  much 
away  to  one  side  of  the  abdominal  wound,  or  in  any  other 
case  where  a  glass  tube  cannot  be  readily  introduced  or  safely 
kept  in  place.  Red  rubber  should  be  used,  and  tubing  of 
several  calibres  will  be  needed.  Small  holes  must  always  be 
cut  in  the  sides  of  the  tube  before  its  introduction,  else  it 
may  fail  to  work  altogether.  After  the  removal  of  the  glass 
tube,  it  is  in  some  cases  advisable  to  introduce  immediately  a 
rubber  tube  of  small  calibre  and  retain  it  for  a  day  or  two. 

The  best  way  to  secure  the  outer  end  of  a  rubber-tube  is 
by  simple  transfixion  with  a  safety-pin,  passed  through  so  as 
to  he  transversely  to  the  abdominal  wound ;  the  pin  should 
pass  through  about  a  quarter  of  an  inch  below  the  cut  end 
of  the  rubber.  Squares  of  carbolized  or  absorbent  gauze,  about 
six  or  eight  layers  thick,  are  then  arranged  above,  below,  and 
on  each  side  of  the  tube,  as  when  glass  is  used. 

The  Many-tailed  Abdominal  Binder. — Surgeons  differ 
in  opinion  as  to  the  best  kind  of  bandage  to  apply  to  the 
abdomen  of  a  patient  after  ovariotomy  or  any  other  form  of 
abdominal  section.  In  every  case  the  operator  must  not  only 
decide  beforehand  what  description  of  bandage  he  will  use,  but 
must  also  make  sure  that  the  nurse  has  made  the  bandage 
wide  enough.  It  is  very  vexatious  to  find,  at  the  conclusion 
of  an  operation  on  a  stout  or  large-framed  woman,  that  the 
ends  of  the  binder  will  not  meet  properly  in  front  of  the 
abdomen. 

Sir  Spencer  Wells  simply  recommends  "  a  flannel  belt," 
which  is  to  be  fastened  around  the  abdomen  by  pins.  Mr.  Tait 
employs  "a  cotton  binder"  fastened  with  safety-pins.  Mr. 
Thornton  gives  more  elaborate  rules  concerning  the  binder. 
He  prefers  a  bandage  made  of  fine  fiannel  and  hned  with 
soft  calico.      He  directs  that  the  calico  should  be  sewn  over 

K 


130  INSTRUMENTS   AND    APPLIANCES. 

the  edges  of  the  flannel  all  round.  A  free  edge  of  flannel 
under  the  patient's  back  is  certain  to  cause  great  irritation. 
The  bandage  is  fixed  with  three  safety-pins. 

The  binder  made  on  the  "many-tailed"  principle,  though 
it  has  but  four  or  five  tails,  is  extremely  convenient.  It  is 
constantly  to  be  seen  in  Dr.  Bantock's  wards,  and  I  always 
employ  it  for  my  own  cases.  When  used,  strapping  is  unne- 
cessary. 

To  make  a  many-tailed  binder,  a  yard  and  a  quarter  of 
flannel,  properly  shrunk,  is  cut  into  strips  about  three  inches 
in  width.  Then  a  square  piece  of  cahco  is  prepared.  It 
must  be  wide  enough  for  its  edges  to  come  well  forwards  on 
both  sides,  when  it  is  placed  evenly  behind  the  patient's  loins, 
so  that  no  flannel  may  touch  the  skin  beyond  the  dressings. 
The  four  strips  of  flannel  are  now  sewn  on  to  the  calico,  each 
strip  overlapping  nearly  half  of  that  sewn  on  before  it.  The 
calico  must  be  sewn  over  the  edges  of  the  highest  and  lowest 
strip,  for  reasons  already  given.  The  breadth  of  the  calico, 
as  just  explained,  will  prevent  the  flannel  from  touching  the 
skin  of  the  flanks. 

When  the  bandage  is  put  on,  after  the  dressings  have  been 
applied  to  the  front  of  the  abdomen,  the  calico  and  not  the 
flannel  must  be  placed  next  to  the  skin  of  the  loins.  In  an 
uncomplicated  case  of  ovariotomy,  where  no  drainage-tube  has 
been  inserted,  and  where  there  is  little  fear  that  the  dressings 
will  have  to  be  frequently  disturbed,  an  overlapped  and  not 
overlapping  strip  of  flannel  must  lie  lowest,  across  the  pubes. 
The  two  ends  of  that  strip  are  drawn,  very  obliquely,  below 
the  anterior  spines  of  the  ilia  and  across  the  iliac  fossae  over 
the  dressings,  as  firmly  as  is  deemed  necessary.  The  ends  must 
overlap  each  other  to  the  extent  of  over  two  inches.  Then  the 
two  ends  of  the  second  strip  are  di'awn  over  the  abdomen 
higher  up,  but  partly  overlapping  the  first  strip :  a  safety- 
pin  should  now  be  fixed  into  the  strips  on  one  side  at  least. 
The  remaining  strips  are  folded  over  the  abdomen  in  the 
same  way,  and  two  or  more  pins  will  be  needed.  They 
must  be  so  placed  as  to  overlap  each  other  evenly,  else  the 
main  object  of  this  bandage — the  undoing  of  one  part  with- 
out disturbing   the  remainder — will   be  defeated.      It   is    im- 


MANY-TAILED    BINDER ABSORBENT   WOOL.  131 

portant  that  the  lower  edge  of  the  calico  should  come  low  down 
towards  the  hips,  else,  as  the  strips  are  applied  obliquely,  the 
lowest  may  pass  above  the  hypogastrium,  so  that  air  will  get 
under  the  dressings. 

In  the  case  of  a  patient  of  large  proportions,  the  flannel  must 
be  longer,  and  the  square  of  calico  greater,  so  that  the  necessary 
conditions,  to  which  I  have  already  alluded,  may  be  satisfied. 

In  cases  where  the  drainage  tube  is  used  after  ovariotomy, 
or  where,  for  any  other  reason,  the  dressings  will  need  frequent 
changing,  and  in  all  cases  of  supra-vaginal  hysterectomy,  the 
many-tailed  binder  must  not  be  applied  as  above  directed,  but 
in  the  reverse  position.  That  is  to  say,  an  overlapping  strip 
of  flannel  must  lie  lowest  when  the  bandage  is  placed  in 
position,  and  the  other  strips  must  be  adjusted  in  the  manner 
described  above,  but  from  above  downwards. 

After  the  bandage  has  been  applied  according  to  the  second 
method  above  described,  the  lower  part  of  the  abdominal  wound, 
the  drainage-tube,  or  the  stump  of  the  uterine  pedicle,  as  the 
case  may  be,  can  be  inspected  by  removing  one  or  two  of  the 
lower  safety  pins,  and  undoing  the  lower  strips  of  flannel. 
The  upper  strips  will  support  the  abdominal  walls  cliu-ing  the 
dressing  of  the  lower  part  of  the  wound.  The  absence  of 
strapping  renders  this  step  quite  simple :  when  the  dressing 
is  completed  the  curgeon  has  merely  to  readjust  the  lower 
strips  of  flannel. 

Two  bandages  should  always  be  made  for  any  case.  At 
the  end  of  a  week,  or  sooner  if  it  be  soiled,  the  first  bandage 
should  be  removed  and  washed.  When  the  patient  has 
recovered  it  is  advisable  that  she  should  wear  an  abdominal 
belt  in  the  day  time,  but  should  put  on  a  many-tailed  bandage 
at  night  for  at  least  six  months. 

Absorbent  Wool. — This  well-known  material  is  of  great 
service  in  dressing  after  many  gynaecological  operations.  The 
best  quality  should  always  be  ordered.  In  order  to  test  it, 
for  samples  must  be  tested  from  time  to  time,  a  pellet  should 
be  dropped  on  the  surface  of  fresh  water  in  a  tumbler.  When 
the  pellet  soaks  in  a  few  seconds  and  sinks,  it  is  a  proof  that 
the  wool  is  really  absorbent.  If,  on  the  other  hand,  the  pellet 
should  float  about,  high   out   of   the  water,  for  a  minute  or 


132 


INSTRUMENTS    AND    APPLIANCES. 


longer,  the  wool  "odll  be  useless  as  an  absorbent  medium. 
The  same  test  will  be  required  for  absorbent  gauze. 

Clover's  Crutch. — This  apparatus  is  exceedingly  serviceable 
in  all  operations  where  the  patient  is  placed  in  the  lithotomy- 
position.  The  lower  extremities  being  kept  apart  artificially, 
there  will  be  no  necessity  to  employ  one  or  two  assistants  for 
the  purpose  of  holding  them  steady. 

The  crutch  (Fig.   56)  consists  of  two  stout  leather  bands. 


Fig.  56.  — C'lovp:r'.s  Ckutch  (the  Inner  Bar  completely  slid  into  the  Outer). 


which  are  each  secured,  by  two  straps,  to  one  of  the  patient's 
thighs  immediately  above  the  knee.  One  band  is  attached  to 
a  solid  bar,  deeply  notched,  the  other  to  a  hollow  bar.  The 
former  bar  is  slid,  between  the  patient's  lower  extremities, 
mthin  the  latter,  and  when  the  knees  are  sufficiently  far 
apart,  they  can  be  fixed  by  turning  a  screw  on  the  hollow  bar, 


CLOVER  S    CRUTCH THORNTOISl  S    ICE-CAP. 


133 


wMcli  thus  catches  in  one  of  the  notches  on  the  solid  bar. 
A  strap  is  attached  to  the  right  side  of  the  crutch  and  is  passed 
behind  the  right  shoulder  and  under  the  left  axilla,  being 
made  fast  to  the  other  end  of  the  crutch,  after  having  been 
pulled  firmly  so  as  to  flex  the  thighs  sufficiently  on  the 
abdomen.  This  strap  must  not  be  pulled  too  tight,  else  it 
will  cause  severe  attacks  of  cramp  in  the  lower  extremities 
after  the  operation.  Care  must  be  taken  that  no  nurse  or 
assistant  presses  on  the  bar  of  the  crutch  or  against  the 
patient's  knee  during  an  operation,  else  the  patient's  body 
will  be  tilted  sideways,  to  the  great  inconvenience  of  the 
operator. 

A  long  piece  of  towelling  makes  a  good  substitute  for  the 
crutch.  One  end  is  made  fast  round  the  right  thigh  just  above 
the  knee,  tied,  and  the  knot  secured  by  a  safety-pin.  The 
towelling  is  then  passed  behind  the  right  shoulder  and  under 
the  left  axilla,  the  other  end  being  secured  to  the  left  thigh, 
after  both  thighs  have  been  flexed  and  sufficiently  abducted. 
The  practice  of  trusting  to  an  assistant  or  nurse  to  hold  the 
thighs  in  position  is  open  to  many  objections. 


Fig.  57. — Thornton's  Ice-cap. 


Thornton's    Ice-cap.*  —  This    apiDhance    (Fig.    57)    is 
modified  from  a  form  invented  by  a  working-man  employed 

*  Originally  described  by  Mr.   Thornton  in  Medical  Times  and  Gazette,  May 
27,  1876,  and  Medico-C'hirurgical  Tramactions,  vol.  Ix.  p.  301. 


134  INSTRUMENTS    AND    APPLIANCES, 

at  an  india-rubber  factory  in  Griasgow.  It  consists  of  a  series 
of  coils  of  stout  gutta-percha  tubing,  joined  together  so  as  to 
form  a  cap.  The  tubing  is  flat  on  the  inner  side,  so  that  a 
uniformly  cool,  smooth  surface  touches  the  patient's  head. 
Before  this  improvement  was  introduced,  the  spaces  which 
necessarily  existed  between  the  perfectly  cylindrical  tubes 
lodged  warm  air  and  defeated  the  object  of  the  apphance. 

At  the  top  of  the  cap  the  tubing  is  continued  as  a  free 
piece,  which  is  to  be  fitted  on  to  a  tap  connected  with  a 
pail.  The  tubing  at  the  lower  border  of  the  cap  is  also 
continued  as  a  free  piece,  several  feet  in  length. 

The  pail  is  filled  with  water  containing  ice — one  large 
block  answers  the  purpose  best.  It  is  placed  on  a  stand  by 
the  side  of  the  bed,  about  two  feet  above  the  level  of  the 
patient's  head.  The  upper  free  piece  of  tubing  is  fitted  to 
the  tap  and  the  water  is  tm^ned  on,  the  cap  being  placed  on 
the  patient's  head.  The  lower  free  piece  of  tubing  passes 
from  the  side  of  the  patient's  head  into  a  pan  beside  the 
bed.  The  tap  may  be  regulated  so  as  to  allow  the  water 
to  flow  slowly.  As  the  pan  fills  the  nm-se  can  bale  out 
some  of  the  water  and  retm^n  it  to  the  pail  above.  She 
must  see  that  another  block  of  ice  is  put  into  the  pail  as 
soon  as  the  first  has  melted  to  trifling  dimensions. 

The  free  tubing  always  needs  adjustment,  for  the  upper 
piece  is  apt  to  bend  so  sharply  at  the  point  where  it  joins 
the  cap  as  to  obstruct  the  flow  of  water,  whilst  the  lower 
bends  so  as  to  obstruct  its  escape.  If  this  bending  be  not 
counteracted  not  only  wiU  the  cap  be  useless,  but  various 
hydraulic  phenomena,  such  as  the  slipping  of  the  upper 
piece  off  the  tap  on  the  pail,  may  occur,  terrifying  the 
patient  and  perplexing  the  nurse.  The  bending  may  be 
counteracted  by  flxing  the  free  tubes,  within  a  few  inches 
of  the  cap,  within  the  loops  of  safety  pins  made  fast  to  the 
pillow,  so  that  each  tube  rises  up  from  the  point  where  it  joins 
the  cap  and  describes  a  short  curve,  which  does  not  obstruct  the 
flow  of  water. 

Letter's  Tube,  Cap,  and  Temperature  Regulator.— 
In  many  respects  the  ice-cap  just  described  is  the  best  apparatus 
for  lowering  high  temperatm-es  after  operation.     Ice,  however, 


letter's  tube,  cap,  and  temperature-regulator.    135 

is  not  always  easy  to  obtain,  and  then  Leiter's  pliable  metal 
coils,  or  "  temperature  regulators,"  are  very  convenient  for 
the  same  purpose,  althoug-h  it  is  always  best  that  the  water 
should  be  ice-cold.  By  means  of  these  coils,  cold  water  may  be 
made  to  circulate  continuously  through  a  length  of  pliable 
metal  tubing.  Leiter's  contrivance  is  employed  for  the  appli- 
cation of  continuous  cold,  or  heat,  to  any  part  of  the  body. 


Fig.  58. — Leiter's  Cap. 

For  the  present  purpose,  the  special  circular  cap  for  the  head 
is  sometimes  employed.  It  may  be  seen  that  it  is  arranged 
like  Thornton's  cap.  A  broad  tape  {b,  Fig.  58)  holds  the  cap 
(Sp)  in  position.  A  supply  vessel  is  placed  above  the  level  of 
the  patient's  head,  and  a  piece  of  gutta-percha  tubing  (;:  s), 
connected   with   the   coils,  is  passed   into  it,  whilst  a  similar 


136 


INSTRUMENTS    AND    APPLIANCES. 


tube  {a  s),  also  connected  "witli  the  coils,  is  placed  in  a  re- 
ceiving vessel  on  the  floor.  By  slight  suction  in  the  lower  tube, 
siphon  action  is  at  once  established.  "When  the  lower  vessel  is 
nearly  full,  the  position  of  the  two  vessels  may  be  reversed,  and 
by  this  repeated  changing,  a  continuous  flow  of  water  thi'ough 
the  spiral  cap  is  maintained  for  any  length  of  time.  According 
to  Leiter,  the  water  "s\'ill  not  require  changing,  provided  that  it 
does  not  rise  to  60°  Fahrenheit.  He  asserts  that  water  under 
50°  causes  an  unpleasant  feeling  of  cold,  for  the  metal  tubing  is 
a  great  conductor  of  heat. 

At  the  Samaritan  Hospital,  however,  it  has  been  found  that 
the  patients  can  tolerate  ice-cold  water  cii'culating  thi'ough 
Leiter's  coils.  Indeed,  it  appears  necessary  that  the  water  in 
the  supply  vessel  should  contain  ice.  Dr.  Bantock,  lDehe\T.ng 
that  the  best  results  are  obtained  when  the  cold  is  applied  to 


Fig.  59.— Leitei;'.><  Tempkuaxtke  Regulatok. 

the  occipital  and  lateral  parts  of  the  head,  rather  than  to  the 
vertex,  prefers  the  long  and  narrow  '' temperatm-e  regulator" 
(Fig.  59).  The  free  ends  can  be  connected  with  gutta-percha 
tubing  for  the  ingress  and  escape  of  the  water  which  chculates 
in  the  coils,  just  as  in  the  case  of  the  cap.  In  order  to  mould 
the  "regulator  "  to  the  shape  of  the  patient's  occiput,  it  shoidd 
be  bent  across  the  thigh,  or  over  some  similarly  broad,  convex 
sm-face,  as  shown  in  Fig.  60.  If  bent  by  the  hands  without 
support  of  this  kind  the  instrimient  will  soon  be  spoilt,  for  the 
coils  will  no  longer  lie  parallel,  so  as  to  touch  the  surface  of  the 
scalp  evenly,  and  they  will  also  become  leaky.  If  the  regulator 
be  bent  too  much,  it  should  be  straightened  as  in  Fig.  61 — the 
palm  must  be  gently  pressed  on  the  prominent  sm-face  of  the 
regulator.  AVhen  properly  bent  into  shape,  the  regulator  is 
placed  behind  the  patient's  head,  the  sides  being  pressed  towards 


letter's    regulator ICE-BLADDERS INSUFFLATOR.      107 

the  temples,  then  the  supply  and  receiving  vessels  and  their 
tubes  are  adjusted. 


Fig.  60. — Leiter's  Temperatuke  Regulator  :    How  to  Bexd  it. 


Fig.  61. — Leiter's  Temperature  Regulator  :    How  to  Straighten  it. 


Ice  Bladders. — A  bladder  of  ice  placed  upon  the  head  is 
more  difficult  to  manage,  and  far  less  satisfactory,  than  either 
of  the  caps  just  described,  yet  if  ice  can  be  freely  procui-ed, 
and  no  better  appliance  be  at  hand,  the  bladder  must  be  used. 
Grreat  precautions  will  then  be  necessary  to  renew  the  ice  before 
that  which  is  already  in  the  bag  has  thawed  completely,  and 
to  prevent  damping  of  the  pillow  from  soakage  through  the 
bladder.  A  piece  of  mackintosh,  carefully  folded,  is  better  than 
a  bladder  as  a  receptacle  for  the  ice. 

Uterine  Insufflator. — This  instrument  is  not  only  useful 
for  the  application  of  powders  to  the  cervix  thi'ough  a  speculimi, 
it  is  also  very  serviceable  for  blowing  pulverized  preparations 


138  l.NS'JllUMENTS    AND    APPLIANCES. 

over  the  surface  of  ca\aties  which  require  to  be  kept  dry  and 
antiseptic,  as  when  an  extra-uterine  foetal  sac  has  been  stitched 
to  the  abdominal  walls.  By  means  of  this  instrument,  the 
powder  can  be  more  thoroughly  applied  than  by  any  other 
method,  and  without  any  fouling  of  either  the  instrument  or 
the  surgeon's  hands  with  septic  products.  The  insufflator  is 
especially  desirable  when  iodofomi  is  applied,  as,  owing  to  its 
odour,  it  is  not  pleasant  for  the  surgeon  if  any  of  that  com- 
pound should  fall  on  his  hands  or  clothes.  This  accident  is 
avoided  by  the  insufflator,  provided  that  it  be  properly  used. 

Clay's  InsuJHator  (Fig.  62)  is  a  convenient  form,  con- 
structed much  on  the  model  of  Rauchfuss's  insufflator.  The 
powder  is  introduced  into  a  hole  in  the  side  of  the  tube,  which 
is  then  covered  over  by  a  cylindrical  sliding  contrivance,  and 


Fig.  62. — Clay'.s  Insufflatok.  (Li  action). 

the  powder  is  ejected  by  pressm-e  on  the  elastic  ball.  The  ball 
also  moves  a  kind  of  stilette,  which  is  dilated  so  as  to  form  a 
knob  or  stopper  to  the  open  end  of  the  tube  when  at  rest. 
Pressure  on  the  ball  pushes  the  knob  forwards,  and  the  powder 
is  scattered.  The  knob  protects  the  powder  fi-om  getting  damp 
and  clogging  the  tube  when  it  is  being  passed  up  the  vagina. 
The  disadvantage  of  any  insufflator  worked  in  this  manner  is 
the  contrivance  by  which  the  powder  is  introduced.  This 
contrivance  does  not  protect  the  surgeon  from  soiHng  of  the 
fingers,  which  in  the  case  of  foetid,  deliquescent,  caustic,  or 
dye-yielding  powders  may  be  very  undesirable.  The  con- 
trivance which  covers  in  the  aperture  in  the  tube  for  the  intro- 
duction of  the  powder  is  apt  to  get  out  of  order,  and  to  sHp  ofi' 
the  aperture  wlion  the  ball  is  being  worked. 
Kabier sky's  Insufflator.— In  this  instrument  (Fig.  63) 


KABIERSKY  S    INSUFFLATOR. 


139 


the  tube  communicates  with  a  bottle  in  which  the  powder  is 
placed.  The  bottle  is  made  flat-bottomed,  so  as  to  stand 
upright  on  a  table.  It  is  generally  rounded  off  at  its  ex- 
tremity. Instead  of  the  ball,  the  handle  of  the  insufflator  is 
sometimes  provided  with  a  spring  stopcock  and  Richardson's 


Fig.  63. — Kabieksky's  Ix.sitfflator,  with  Flat-bottomed  Glass  Reservoij: 
[Nozzle  not  Attached). 

ether-spray  bellows.  During  use,  the  ball  covered  with  net- 
work is  first  inflated  by  pressure  on  the  lower  ball,  then,  by 
pressure  on  the  metal  plate  of  the  spring  stopcock,  the  air 
is  released  from  the  ball,  and  the  powder  is  blown  on  to  the 
sm^face  towards  which  the  nozzle  is  directed.  The  simple  india- 
rubber  ball,  however,  answers  very  well,  so  that  the  bellows  are 
hardly  needed. 

The   tube   of   Kabiersky's  insufflator  is  made  of  vulcanite, 
and  nozzles  of  different  shapes  are  made  (Fig.  64,  in,  I,  and  J-c)  ;  of 


Fig.  64. — Nozzles  for  Kabiersky's  Insufflator. 

these,  /,  designed  originally  for  the  pharynx,  is  best  for  applying 
powders  to  the  vagina,  or  cervix,  or  uterine  canal;  m  for 
blowing  into  the  cavity  of  a  tumour  or  extra-uterine  foetal 
sac  undergoing  desiccation  after  drainage. 

The  glass  bottle  is  fixed  to  the  tube  by  means  of  a  bayonet- 
joint.  It  must  be  kept  pointing  downwards  when  it  is  advisable 
to  apply  the  powder  in  the  finest  state  of  division  possible,  but 
upwards  when  a  thick  layer  of  powder  is  desired. 


140  INSTRUMENTS    AND    APPLIANCES. 

This  is  an  excellent  instrument,  and  the  glass  bottle  is 
readily  taken  off  and  put  on  when  required.  In  the  case  of 
a  powder  often  applied,  especially  iodoform,  it  is  convenient 
in  hospital  practice  to  keep  the  bottle  constantly  filled  and 
fixed  to  the  insufflator,  which,  thus  charged,  may  be  kept  in 
the  out-patient  room  or  operating  theatre,  or  taken  round  the 
wards  ^vith  other  di'essing  implements. 

Antiseptics  in  Ovariotomy,  and  other  Varieties  of 
Abdominal  Section. — The  relative  merits  of  Listerian  and 
non-Listerian  ovariotomy  cannot  be  compared  in  these  pages. 
The  question  has  been  actively  discussed  in  the  medical  press, 
and  in  the  writings  of  those  specialists  whose  names  I  fre- 
quently mention  throughout  this  manual.  I  have  not  as  yet 
discarded  antiseptics  in  my  own  practice,  but  I  am  ready  to 
admit  that  those  who  have  performed  abdominal  section  many 
hundreds  of  times  appear  to  be  in  a  position  to  dispense  at  least 
with  the  spray. 

When  the  spray  and  a  l-in-40  carbolic  solution  are  both 
discarded,  the  instruments  must  be  kept  in  warm  water,  when 
not  actually  in  hand.  For  full  particulars  of  the  principles 
of  antiseptic  ovariotomy,  I  must  refer  the  reader  to  Mr. 
Thornton's  article  on  that  operation  in  Heath's  Dictionary  of 
Practical  Surgery,  for  that  author  is  the  j)rincipal  authority  on 
the  subject. 

The  spray-apparatus,  when  it  is  used,  should  be  placed  about 
eight  feet  from  the  seat  of  operation.  If  too  neai%  the  jet  of 
steam  will  not  be  diffused  over  a  sufficiently  T\-ide  area  of  the 
parts  subjected  to  operation ;  it  will  also  cause  needless  irrita- 
tion, and  ^dll  make  the  operator's  hands  numb,  greatly  impairing 
their  tactile  sensibility,  which  is  so  necessary  for  exploration  of 
the  viscera. 


141 


CHAPTER   V. 

ELECTRICAL   APPARATUS   USED    IN   GYNECOLOGICAL   SURGERY 

Introduction.  —  Electrical  contrivances  are  extensively 
used  both  in  operations  on  women  and  in  the  treatment  of 
their  diseases.  I  have  endeavoured  to  avoid  the  error  of 
taking  for  granted  that  the  reader  is  acquainted  with  the 
batteries  employed  for  these  purposes,  and  that  he  under- 
stands the  technical  terms  used  by  electricians.  Therefore, 
I  have  availed  myself  of  the  services  of  Dr.  Steavenson, 
physician  in  charge  of  the  Electrical  Department  of  St. 
Bartholomew's  Hospital,  who  has  kindly  written  this  chapter 
which  may,  I  believe,  help  to  instruct  the  reader  so  that  he 
may  know  what  instruments  to  procure,  how  to  use  them,  and 
how  to  teach  their  use  to  his  assistants. 

Galvano  -  cautery  and  Electrolysis. — Electricity  is 
employed  in  operative  surgery  in  two  ways.  Firstly,  it  is 
used  for  its  power  of  producing  heat ;  and  secondly,  for  its 
property  of  splitting  up  all  chemical  compounds,  that  are 
conductors,  into  their  constituent  elements.  These  two  proper- 
ties of  electricity  go  under  the  relative  names  of  galvano- 
cautery  and  electrolysis.  For  the  employment  of  either  in 
surgery,  batteries  of  different  construction  and  diiferent  instru- 
ments are  required. 

In  galvano-cautery  the  cu-cuit  is  completed  thi'ough  the 
instrument  that  is  used  (see  Figs.  68,  69,  70),  and  therefore  the 
resistance  offered  to  the  current  is  very  low,  and  every  endea- 
vour is  made  to  further  reduce  it.  In  electrolysis  each  pole 
is  attached  to  a  separate  electrode,  and  the  circuit  completed 
through  the  body  of  the  patient,  which  offers  a  very  high 
resistance  to  the  current ;  therefore,  means  have  to  be  adopted 
for  overcoming  this  resistance. 


142  ELECTRICAL    APPARATUS. 

The  constant  current,  as  it  is  called,  is  the  kind  of  electricity 
which  is  used  for  accomplishing  both  objects. 

In  galvano- cautery  the  battery  is  arranged  so  as  to  give  a 
large  quantity  of  electricity  in  a  short  space  of  time,  and  in 
electrolysis  the  battery  is  so  arranged  as  to  enable  it  to  over- 
come a  high  external  resistance.  Although  both  the  batteries 
which  are  used  produce  a  constant  current,  they  are,  on  account 
of  the  different  arrangement  of  the  cells,  usually  called  by 
distinctive  names.  One  is  called  a  galvano-caiitery  battery,  and 
the  other  a  galvanic  or  constant  current  battery. 

Initial  Force  :  Electro  -  motive  Force. — The  initial 
force  by  which  electrical  separation  takes  place  in  a  cell 
depends  upon  the  elements  of  which  the  cell  is  composed,  and 
the  activity  with  which  the  exciting  fluid  attacks  the  positive 
element  (usually  zinc)  when  the  circuit  is  closed.  Again,  the 
amount  of  this  chemical  decomposition  of  the  positive  element 
is  regulated  by  the  strength  of  the  current.  This  initial  force 
is  called  potential.  The  difference  of  potential  thus  established 
in  the  elements  of  a  cell  produces  electro-motive  force,  and 
electro-motive  force  is  that  force  which  tends  to  move  electricity 
in  a  circuit  when  the  current  is  closed.  It  therefore  follows 
that  whatever  the  size  of  the  cell  or  of  the  elements  contained 
in  the  cell,  if  composed  of  similar  materials,  the  same  electro- 
motive force  is  produced.  Therefore,  the  electro-motive  force 
(E.  M.  r.)  of  cells  of  like  construction  is  the  same,  no  matter 
what  their  size. 

The  Volt. — The  Yolt  is  the  standard  of  electro-motive 
force,  and  is  very  nearly  the  electro- motive  force  produced  in 
one  Daniell's  cell. 

The  most  common  cells  used  in  medicine  are  : — 

Daniell's  ;  electro-motive  force .  . 
Smee's  ,,  ,,        .  . 

Leclanchc's        ,,  „        .  . 

Chloride  of  silver  ;  electro-motive  force 
Stohrer's  „  ,,    •  • 

Grrove's  „  55    .  • 

Bunsen's  ,,  ,,    •  • 

Bichromate  of  potash     ,,  ?,    •  • 


1-079  volts. 

1-62 

1-5 

•915 

1-825 

1-956 

1-964 

2-000 

THE    VOLT— OHM — STRENGTH    OF    CURRENT.  143 

Tlie  last  tkree,  with  a  higli  electro-motive  force,  are  em- 
ployed chiefly  for  galvano-cautery. 

The  Ohm. — The  unit  of  resistance  is  the  ohm.  An  ohm 
is  the  amount  of  resistance  offered  by  48|  metres  of  copper 
wire  of  one  millimetre  diameter.  Dr.  Stone,  of  St.  Thomas's 
Hospital,  has  shown*  that  the  human  body  offers  a  resistance 
of  from  900  to  1,000  ohms. 

Strength  of  Current. — The  strength  of  current  of  a 
battery  is  determined  by  the  accumulated  electro-motive  force 
of  the  cells  divided  by  the  resistance.  This  is  what  is  called 
Ohm's  law,  and  may  be  expressed  by  the  formula  : — 

E 


C.  S.  = 


Ei+E,, 


in  which,  C.  S.  =  cm-rent  strength  ;  E  =  electro-motive  force  ; 
E,^  =  external  resistance ;  and  Rg  —  internal  resistance.  It  is 
therefore  evident  that  the  current  strength  mil  greatly  depend 
upon  the  amount  of  resistance.  The  internal  resistance  E-^  is 
always  low ;  therefore,  if  E,^  be  relatively  great,  means  must 
be  taken  to  increase  the  value  of  our  numerator,  the  electro- 
motive force.  This  is  done  by  multiplying  the  number  of 
cells.  But  if  11;^  be  small,  the  current  strength  can  be  greatly 
increased  by  reducing  R^  (making  our  denominator  low,  and 
therefore  our  quotient  high).  This  is  done  by  increasing  the 
size  of  the  cells  and  surfaces  of  the  elements.  "  By  reference 
to  these  facts  we  determine  the  form  of  battery  to  be  used 
in  the  different  applications  of  electricity  to  medicine  and 
surgery."! 

For  instance,  if  R^  =  1,000  ohms  and  Rg  —  1  ohm,  to  reduce 
Rg  to  2"  an  olina  would  leave  the  whole  resistance  at  1,000 
I  ohms.  This  would  not  materially  affect  the  strength  of 
the  current :  it  would  only  increase  the  current  strength  by 
about  o o'^oo-  pai'^'-  -But  if  Rj  =  1  ohm  and  R,  =:  1  ohm,  then 
to  reduce  Rg  to  \  an  ohm,  by  doubling  the  size  of  the  plates 
in  the  cell,  the  current  strength  Avould  be  increased  by  \.  This 
is  the  object  attained  by  a  galvano-cautery  battery. 

*  "  Liimleian  Lectures  before  the  Royal  College  of  Physicians  of  London'" 
(British  Medical  Journal,  vol.  i.,   1886,  pp.   728,  812,   863). 

t  John  Duncan:  'Hea.th.'?,  Dictionary  of  Practical  Surgery,  article  "Electrolysis." 


144 


ELECTRICAL    APPARATUS. 


The  Ampere. — An  amiDere  is  the  unit  of  current  strengtli, 
and  is  produced  by  one  volt  through  the  resistance  of  one 
ohm.    In  medicine,  yoVo  of  sm  ampere  or  a  milliampere  is  used. 

The  Coulomb. — The  coulomb  is  the  unit  of  quantity,  and 
is  the  quantity  of  electricity  that  will  pass  through  a  eii-cuit 
in  one  second  when  the  current  strength  is  one  ampere. 

The  current  strength  of  one  volt  through  one  ohm  for  three 
seconds  is  still  one  ampere,  but  the  quantity  is  three  coulombs. 

The  Galvano-cautery  Battery. — This  kind  of  battery 
(Fig.  65)  has  to  overcome  a  relatively  low  external  resistance, 


Flfi.    65. — BlCHKOMATK   OF    ToTASH    GaLVANU-CAUTEHY    BaTTEHY,    ^VITH 

Elf.ctiiode. 

A,  B,  terminals  for  attaching  the  conducting  cords  to  the  rheostat  and  carbon 
pole  of  the  battery.  C,  D,  connection  between  the  two  sets  of  plates.  E,  F, 
connection  between  the  second  group  of  zincs  and  the  rheostat,  thus  completing 
the  circuit.    A,  F,  rlieostat  woiked  by  a  sliding  button,  G,  between  the  terminals. 

and  therefore  the  cmTent  strength  is  greatly  increased  b}' 
reducing  the  internal  resistance  to  a  minimum.  This  is  done 
by  having  large  cells  with  elements  exposing  wide  surfaces  to 
the   exciting   fluid,  and   closely  approximated   to   each   other. 


GALVANO-CAUTERY    BATTERY RHEOSTAT AMALGAMATION.       145 

The  current  strengtli  is  therefore  great,  and  the  quantity  of 
electricity  passing  in  a  given  time  is  also  great.  A  few  such 
large  cells  are  found  sufficient  to  heat  a  xDlatinum  wire.  One 
of  the  best  forms  of  galvano-cautery  batteries  (Fig.  65)  is 
composed  of  four  or  six  cells  (two  in  the  diagram)  ;  each  cell  is 
composed  of  four  or  five  broad  plates  of  zinc  about  half  an 
inch  apart,  and  on  either  side  of  these  plates  is  a  similar- 
sized  plate  of  carbon.  By  this  arrangement  in  each  cell  there 
is  one  more  carbon  plate  than  zinc.  This  is  found  to  be  an 
advantage.  The  carbon  plates  are  not  allowed  actually  to 
touch  the  zinc.  All  the  zinc  plates  composing  each  cell  are 
joined  together  usually  on  an  iron  frame,  and  virtually  form  one 
element  of  considerable  surface.  They  can  be  removed  together 
for  the  pm-pose  of  cleansing  and  re-amalgamation,  and  in  some 
cases  for  lifting  from  the  exciting  fluid  when  the  battery  is 
not  in  use.  All  the  carbon  plates  of  each  cell  are  also  joined 
together,  and  make  one  large  negative  element.  Thej^  are 
usually  fixed  to  the  element  board,  for  it  does  not  matter  if  the 
carbons  be  left  in  the  fluid,  as  they  are  not  affected  by  it. 
The  exciting  fluid  is  composed  of  a  saturated  solution  of 
bi-chromate  of  potash,  with  one  ounce  of  pure  sulphuric  acid 
added  to  every  seven  ounces  of  the  solution.  Both  elements 
are  immersed  in  this  fluid  when  the  battery  is  at  work.  The 
fluid  is  contained  in  glass  or  vulcanite  cells.  The  best  method 
for  bringing  the  battery  into  play  is  to  have  these  cells  con- 
taining the  fluid  on  a  stage  which,  by  a  mechanical  arrange- 
ment attached  to  the  lid,  can  be  brought  up  to  the  elements 
by  turning  the  lid  back  from  the  perpendicular  (Fig,  65).  This 
arrangement  also  obviates  the  necessity  of  a  rheostat,  for  the 
current  can  be  regulated  by  the  amount  of  the  plates  which 
the  fluid  is  allowed  to  cover.  In  this  way  an  assistant,  with 
his  hand  on  the  lid,  can  so  control  the  current  that  the 
cauter  or  wire  is  kept  at  a  dull  or  bright  red  heat. 

The  Rheostat. — A  rheostat  is  an  arrangement  for  regu- 
lating the  current  by  interposing  more  resistance,  and  is 
generally  made  of  a  coil  of  Grerman  silver  wire.  The  cm-rent  is 
made  to  traverse  more  or  less  of  this  coil,  according  to  the 
amount  of  heat  required. 

Amalgamation.  —  Another     advantage     of     Ihe    Hfting 


146  ELECTRICAL    APPARATUS. 

arrangement  attached  to  the  lid  is,  that  at  any  time  during  the 
operation,  when  the  cui'rent  is  not  required,  the  fluid  can  be 
lowered  and  the  zincs  left  clear.  Although  theoretically  no 
action  ought  to  go  on  in  a  cell  when  the  cu-cuit  is  open,  yet,  as 
a  matter  of  fact,  local  action  does  take  place  in  the  zinc,  owing 
to  certain  metalhc  impurities  which  it  always  contains.  To 
obviate  this  local  action  as  much  as  possible,  it  is  advisable  to 
have  the  zinc  plates  well  amalgamated.  After  every  second 
or  third  operation  the  plates  should  be  re-amalgamated.  This 
process  of  amalgamation  can  be  easily  accomplished.  The 
sirrface  of  the  zinc  is  cleaned  with  a  little  dilute  sulphuric 
acid  and  water,  and  then  some  crude  mercury  is  poured  upon 
each  surface  and  rubbed  into  it  by  a  piece  of  linen  rag  tied 
over  the  end  of  a  stick.  The  mercury  unites  vrith.  the  zinc, 
and  forms  a  bright  metallic  layer. 

Polarization. — Another  action  which  impedes  and  weakens 
a  current  is  called  polarisation.  This  takes  place  on  the 
negative  element,  the  carbon.  Hydrogen  is  displaced  by  the 
action  of  sulphuric  acid  on  zinc,  and  appears  at,  and  adheres 
to,  the  carbon,  forming  a  film  of  minute  bubbles,  which  mate- 
rially increases  the  internal  resistance  of  the  cell  and  weakens 
the  current. 

To  obviate  polarization,  many  devices  are  followed.  1. 
Bi-chromate  of  potash  is  used  in  the  exciting  fluid,  as  it 
easily  parts  with  its  oxygen,  which  combines  with  the  nascent 
hydrogen.  2.  The  cell  is  rocked  to  and  fro  to  mechani- 
cally disengage  the  bubbles  of  hydrogen.  3.  Apiece  of  vulcanite 
is  made  to  pull  up  and  down  over  the  carbons,  so  as  to  sweep 
their  surfaces.  4.  The  lifting  arrangement,  before  described,  is 
also  useful  in  disengaging  this  layer  of  hydrogen.  The 
strength  of  a  cun^ent  can  often  be  increased  by  bending  the 
lid  sharply  once  or  twice  backwards  and  forwards,  thus  washing 
the  hydrogen  off  the  carbons  by  the  movement  of  the  fluid. 
But  the  chief  cause  of  weakness  in  a  bi-chromate  of  potash 
battery,  and  the  reason  why  it  runs  down  far  more  rapidly 
than  a  Bunsen's  or  a  Grrove's  battery,  is  that  the  exciting 
fluid  soon  becomes  what  the  electricians  call  "killed."  In 
other  words,  the  sulphuric  acid  is  gradually  used  up  and 
turned  into  a  solution  of   sulphate  of   zinc.      It  is,  therefore, 


POLARIZATION BUNSEn's    BATTERY.  147 

necessary  to  change  the  fluid  frequently.  The  same  fluid  will 
not  do  for  more  than  two  or  three  operations  ;  it  then  has  to 
be  thrown  away  and  fresh  fluid  used.  It  is  best,  when  a  long- 
operation  is  anticipated,  always  to  begin  with  fresh  fluid. 
A  bi-chromate  of  potash  galvano-cautery  battery  will  work 
very  well  for  most  operations,  which  do  not  take  more  than 
twenty  minutes  or  half  an  hour ;  but  towards  the  end  of  that 
time  the  strength  of  the  current  is  considerably  reduced.  The 
exhaustion  of  the  fluid  can  be  retarded  by  attention  to  the 
direction  before  given ;  that  is,  by  lowering  the  fluid  away 
from  the  elements  at  every  opportunity  during  the  operation 
when  the  current  is  not  actually  required — at  such  intervals, 
for  example,  as  those  caused  by  the  necessity  for  readjusting 
the  wire  or  changing  the  cauter.  The  bi-chromate  of  potash 
battery  has  an  advantage  over  the  Bunsen's  or  Grrove's  in 
that  the  operator  and  bystanders  are  spared  the  annoyance  of 
the  nitric  acid  fumes  which  are  always  given  off  from  these 
batteries. 

Bunsen's  Battery  for  Galvano-cautery. — This  con- 
sists of  four  to  six  cells,  composed  of  zinc  and  carbon,  but  the 
elements  are  contained  in  separate  cells,  and  immersed  in  differ- 
ent fluids.    The  carbon  is  placed  in  a  porous  earthenware  inner 


pot,  containing  concentrated  nitric  acid;  around  the  pot  is  a  circu- 
lar sheet  of  zinc  immersed  in  sulphuric  acid  and  water  (1  to  8), 
and  all  contained  in  an  outside  glazed  earthenware  or  glass 
pot  (Fig.  66).  The  electro-motive  force  of  a  Bimsen  battery 
is  rather  higher  than  that  of  a  Grrove's,  and  carbon  is  much 
cheaper  than  the  platinum  used  in  the  latter  cell ;  but  in  the 
Bunsen  cell  it  is  somewhat  difficult  to  get  a  good  connection 


148 


ELECTRICAL    APPARATUS. 


between  the  strip  of   copper  wliicli   unites  the  zinc  plates  to 
the  carlion,  on  account  of  the  rough  surface  of  the  carbon. 

Grove's  Battery  (Fig.  67)  is  similar  to  Bunsen's,  except 
that  in  the  inner  pot  platinum  takes  the  place  of  carbon. 
Although  in  both  the  cells  a  porous  j^ot  is  introduced  between 
the  positive  and  the  negative  element,  yet  the  internal  resistance 
is  low,  on  account  of  the  good  conducting  power  of  the  nitric 
acid.  In  neither  of  these  cells  does  polarization  take  place, 
because  the  hydrogen  which  is  liberated  by  the  decomposition  of 


Fk;.  67. — Gjiuve's  Battkuy,  with  Kcr.AsEn: 


zinc  in  dilute  sulphuric  acid  has  to  pass  thi"Ough  nitric  acid  before 
it  can  be  deposited  on  the  negative  element  (carbon  or  platinum). 
In  passing  through  the  nitric  acid  the  hydrogen  becomes 
oxidized,  and  red  fumes  of  j^eroxide  of  nitrogen  escape  from 
the  battery.  These  red  fumes  make  the  Grrove's  and  Bunsen's 
batteries  objectionable  for  sm-gical  work.  In  hospitals  and  large 
institutions,  where  space  can  be  given  for  a  regularly  organized 
electrical  department,  these  batteries  can  be  kept  in  a  dr}' 
cellar  beneath  the  operating-room,  and  are  far  cheaper  and  more 
effectual  than  any  other  form,  as  a  current  capable  of  heating  a 


grove's    battery RHEOPHORES CAL'TERS.  149 

platinum  wire  and  performing  an  operation  can  be  maintained 
for  several  hours.  They  cannot  be  kept  charged,  because  the 
acid  fumes  which  arise  from  them  destroy  the  connections.  It 
is  therefore  almost  necessary  to  have  an  electrician;  whose  duty 
it  is  to  prepare  the  battery  when  it  is  required,  to  decant  the 
fluid  and  wash  the  elements  directly  the  operation  is  over,  and 
to  keep  all  the  connections  dry  and  bright.  A  Grrove's  battery 
can  be  made  in  a  more  portable  form  (Fig.  67)  than  a  Bunsen's, 
on  account  of  the  smaller  space  required  by  the  platinum, 
which  can  also  be  placed  in  a  flat  porous  cell,  and  the  zinc  can 
be  bent  up  so  as  to  embrace  the  flat  porous  cell  on  both  sides ; 
this  helps  to  reduce  the  internal  resistance. 

Rheophores. — The  rheophores  are  the  conducting  cords 
between  the  battery  and  the  instrument  with  which  the  operation 
is  performed,  and  are  usually  composed  of  thick  copper  wire,  or 
many  strands  of  fine  copper  wire.  For  galvano-cautery  purposes 
the  rheophores  are  made  thick — ^that  is,  of  as  large  a  transverse 
sectional  area  as  is  possible,  so  as  to  offer  very  slight  resistance 
to  the  transit  of  the  current.  One  rheophore  is  attached  by  a 
binding-screw  to  the  first  carbon  or  platinum  element  of  the 
battery,  forming  the  positive  pole,  and  the  other  is  attached  to  the 
last  zinc,  forming  the  negative  pole.  The  circuit  outside  the 
battery  is  from  the  carbon  to  the  zinc  ;  inside  each  cell,  from  the 
zinc  to  the  carbon.  Each  rheophore  is  attached  by  a  separate 
binding-screw  to  the  handle  of  the  instrument. 

Instruments :  Cauters. — The  instruments  vary  in  shape 
and  construction  according  to  the  operation  for  which  they  are 
required.  In  most  of  them  the  cm-rent  passes  to  and  from  the 
cauter  through  the  same  handle,  by  means  of  two  metal  rods,  fre- 
quently made  of  brass.  The  rods  are  insulated  from  each  other 
up  to  the  point  of  the  instrument,  where  connection  is  made 
between  them  by  some  comparatively  badly  conducting  metal,  of 
small  sectional  area,  usually  platinum.  Owing  to  the  increased 
resistance  and  greater  density  of  the  cm-rent  thus  produced  in 
this  terminal  part  of  the  instrument,  heat  is  evolved  in  sufficient 
quantity  to  raise  the  temperature  of  the  platinum  to  any 
requii-ed  degree.  In  the  handle,  the  conducting  rods  are 
insulated  by  being  each  separately  embedded  in  ebonite ;  and 
beyond  the  handles,  up  to  the  uniting  piece  of  platinum,  each 


150  ELECTRICAL    APPARATUS. 

stem  is  covered  mth  shellac,  or  other  insulating  substance,  and 
bound  round  with  cotton,  also  covered  with  shellac.  No  metallic 
connection  takes  place  by  which  the  ciu-rent,  after  leaving  the 
battery  by  the  positive  pole,  can  retm-n  to  the  negative  pole, 
except  through  the  piece  of  platinum  which  it  is  required  to  heat. 
If  the  current  does  find  its  way  back  to  the  battery,  through  any 
imperfect  insulation  in  the  instruments,  or  by  carelessness  on 
the  part  of  the  operator  in  letting  his  instruments  touch  some 
metal  part  of  the  battery,  the  cm-rent  is  said  to  be  "  short 
circuited,"  and  does  not  reach  the  platinum  at  all.  Platinum  is 
generally  used  to  form  the  actual  bm-ning  part  of  the  instrument, 
and  is  selected  because  of  the  great  resistance  it  offers  to  the 
transit  of  electricity,  being  a  very  bad  conductor,  and  because 
of  its  high  fusing  point.  Platinum  is,  of  all  malleable 
metals,  the  worst  conductor  of  both  heat  and  electricity,  and  is 
also  the  least  oxidizable.  The  shortest  piece  of  platinum  or  the 
finest  wire,  compatible  with  the  operation  which  it  is  intended 
to  perform,  is  selected,  because  the  finer  the  wire  the  greater 
the  density  of  the  electricity  which  passes  in  a  given  time. 

Whereas,  in  every  other  part  of  the  circuit,  every  endeavour  is 
made  to  allow  the  current  to  flow  along  broad  conducting  routes 
as  easily  as  possible,  at  the  point  where  heat  is  to  be  evolved 
every  obstacle  is  placed  in  the  way  of  the  cm-rent,  so  as  to  have 
the  largest  amount  of  electricity  passing  through  a  point  of  high 
resistance.  The  transverse  sectional  area  of  this  part  of  the 
circuit  which  offers  high  resistance  is  also  made  as  small  as 
possible,  so  that  the  density  of  the  current  may  be  increased. 
If  the  transverse  sectional  area  of  a  platinum  wire  used  to 
complete  the  circuit  be  too  small  for  the  strength  of  cm-rent, 
the  heat  evolved  will  be  so  great  that  the  wire  will  fuse, 
although  platinum  has  the  highest  fusing  point  (1775^  C.)  of 
any  known  metal.  By  electricity  we  are  able  to  produce  the 
highest  degree  of  heat  hitherto  known,  and  we  are  also  able  to 
regulate  and  control  its  production  in  a  manner  perfectly 
impossible  in  the  case  of  any  other  heat-generating  force. 

The  terminal  ends  of  platinum  are  made  of  different  sizes 
and  shapes,  so  as  to  be  suitable  for  very  different  pm-poses. 
Some  are  made  with  a  small  loop  which  can  be  used  for  the 
removal  of   m-ethral  caruncles  ;    others  are  brought  to  a  fine 


CAUTERS PLATINUM   KNIFE. 


151 


point  with  wliich  sinuous  passages  can  be  cauterized ;  while  others 
again  are  made  of  flat  pieces  of  platinum  to  which  the  name  of 
"  platinum  knives "  has  been  given.  For  the  purpose  of 
arresting  hsemorrhage  or  destroying  unhealthy  surfaces,  broad 
nodular  ends  are  made  of  porcelain,  round  which  platinum  wire 


Fig.  68. — Cauters  and  Ecraseuk. 

is  coiled  (Fig.  Q8).  The  wire  when  red-hot  heats  the  porcelain, 
which  also  becomes  red-hot,  and  retains  the  heat  for  some 
time ;  thus  a  more  permanent  cautery  is  obtained,  and  one  not 
so  likely  to  be  damped  and  cooled  by  the  moist  tissues  and  blood 
as  a  smaller  cauter  composed  only  of  a  thin  piece  of  platinum. 
Platinum  Knife. — The  so-called  platinmn  knives  are  too 
weak  and  yielding  to  be  used  in  the  same  way  as  a  Paquelin's 
thermo- cautery  knife.     To  supply  this  want,  a  platinum  knife 


Fig.  69. — Fiem  Platinum  Knife. 
It  consists  of  a  porcelain  knife,  of  whicli  the  edge  is  of  platinum. 

has  been  made  which  consists  of  a  stout  piece  of  platinum  wire 
stretched  round  the  edge  of  a  tongue-shaped  piece  of  porcelain 
(Fig.  69).     When  employed  with  the  battery,  the  wii'e  becomes 


152 


ELECTRICAL    APPARATUS. 


red-hot,  and  will  cut  in  the  same  way  as  a  benzoline  cautery, 
the  M-ire  being  kept  firm  and  in  position  by  the  porcelain. 

Galvanic  Ecraseur. — The  galvanic  ecraseur  is  an  instru- 
ment in  which  a  loop  of  heated  platinum  or  steel  wire  can  be 
gradually  contracted.  It  is  used  for  the  removal  of  pedun- 
culated growths,  the  cancerous  cervix  uteri,  hypertrophied 
anterior  hp,  or  polypi.  The  loop  is  shortened  by  attaching  the 
wire  to  an  ivory  sHde  which  is  able  to  be  moved  up  and  down 
a  groove  in  the  handle  of  the  instrument.  Slides  are  made 
which  can  be  either  retracted  by  the  finger  or  moved  down  the 
groove  by  a  screwing  arrangement  as  in  an  ordinary  ecraseur. 


YiG.  70. — Galvanic  Eceaseuk. 

A,  platinum  loop,  b,  lAece  of  porcelain,  a  non-conductor,  c,  piece  of  ivory. 
The  currunt  runs  along  the  metal  rods,  D  D,  until  it  comes  to  the  place  where 
they  are  separated  by  the  porcelain  ;  thence  it  completes  the  circuit  through  the 
small  loop  of  platinum  wire,  which  becomes  red-hot. 

The  vare  passes  through  little  holes  in  the  ends  of  the  brass 
rods  which  convey  the  cmTent  through  the  handle.  The  ends 
of  the  rods  are  kept  apart  and  insulated  from  each  other  by  a 
small  piece  of  porcelain.  The  eyes  tlirough  which  the  platinum 
wire  is  threaded  must  not  be  too  large,  as  good  contact  between 
the  brass  carriers  and  the  wire  is  necessary  to  complete  the 
circuit,  the  current  being  conveyed  from  the  brass  rods  to  the 
wire.  At  the  other  ends  of  the  brass  or  steel  rods,  where  they 
emerge  from  the  handles,  are  binding-screws,  to  one  of  which  is 
attached  the  rheophore  from  the  positive  pole,  and  to  the  other 
the  rheophore  from  the  negative  pole.  The  circuit  is  closed  by 
a  spring  arrangement,  which  is  moved  from  the  under  sm-face 


THE    GALVANIC    ECRASEUR. 


153 


of  the  handle,  and  is  generally  pressed  by  the  ring  finger  as 
shown  in  Fig.  71. 


I     Jjjjii^JimimMlil'^'^'iJi^ 


Fig.  71. — Side  View  of  the  same  Galvanic  Ecra^eur  (see  Fig.  70). 
ShoAvius  the  manner  in  ■which  tlie  instrument  should  be  held. 


Fig.  72. — Twu  Clip-Haxdles. 
A,  platinum  loop,     b,  shunt  for  interrupting  or  completing  current. 

Some   operators   prefer  that   the   platinum   wire   should   be 
connected  with  two  conducting  handles  (Fig.  72),  one  handle 


154  ELECTRICAL    APPARATUS. 

connected  mth  the  positive  pole,  and  the  other  mth  the  negative 
pole  of  the  battery.  The  wire  connected  in  this  way  gives  the 
operator  great  power  in  directing  the  course  that  it  should 
follow  in  biu-ning  its  way  through  the  tissues  it  is  intended  to 
remove.  It  is  found  most  useful  in  the  removal  of  hyper- 
trophied  vulvae,  diseased  clitoris,  cauliflower  excrescences  and 
condylomata,  and  also  the  cer\dx  uteri  when  it  can  be  drawn 
do"«Ti  sufficiently  to  be  brought  into  view.  The  growth  or 
tuniom^  has  to  be  held  by  an  assistant,  as  with  this  instrument 
both  hands  of  the  operator  are  required. 

Control  and  Application  of  the  Instruments. — In 
all  the  instruments  used  with  the  galvano-eautery  battery  some 
mechanical  arrangement  exists  in  the  handle  for  completing  or 
opening  the  circuit,  so  that  the  commencement  and  arrest  of 
the  cauterizing  action  may  be  entirely  under  the  control  of  the 
operator.  With  some  batteries  an  arrangement  exists  by  which 
the  continuity  of  the  em-rent  can  be  made  or  broken  by  the 
foot ;  the  strength  of  the  cm-rent  can  also  be  regulated  by  this 
means.  The  mode  of  appKcation  of  the  instruments  above- 
mentioned  is  obvious  from  the  description  of  them  already 
given.  The  wire  of  the  galvanic  ecraseur  is  appHed  in  the  same 
manner  as  with  other  ecrasem-s,  and  the  wii-e  tightened  by  a 
similar  action.  But  the  tightening  of  the  wii-e  is  not  the  force 
with  which  the  operation  is  performed.  Care  should  be  taken 
not  to  tighten  it  too  rapidly,  so  as  to  make  it  cut  thi^ough  the 
tissues  ;  it  should  be  allowed  to  burn  its  way  through  them,  and 
only  drawn  tight  enough  to  keep  its  red-hot  sm-face  against 
those  parts  that  have  not  abeady  beeu  divided.  If  tightened 
too  fast,  the  wire  itself  cuts  the  tissues,  and  its  haemostatic 
action  has  not  time  enough  to  seal  the  divided  ends  of  the 
vessels  ;  hcemon-hage  might  therefore  take  place.  The  same 
remark  applies  if  the  wire  be  used  too  hot.  A  ^vire  at  a  white 
heat  would  cut  thi'ough  like  a  knife,  and  haemorrhage  would 
follow.  One  of  the  chief  advantages  of  the  galvanic  ecrasem' 
would  thereby  be  lost.  The  Avire  ought  to  be  kept  at  a  dull  red 
heat.  The  assistant,  therefore,  who  has  charge  of  the  battery 
and  who  has  to  regulate  the  cmTcnt  ought  to  be  experienced, 
for  on  him  depends  to  a  great  extent  the  success  of  the 
operation.     He  ought  to  be  constantly  using  a  galvano-eautery 


APPLICATION    AND    ADVANTAGES    OF    THE    GALYANO-CAUTERY.    155 

battery,  and  know  the  particular  battery  which  he  may  be 
called  upon  to  work.  When  acting  well,  a  slight  hissing  sound 
is  heard  during  the  operation.  If  the  wire  were  kept  too  long, 
each  end  of  the  loop  not  embedded  in  the  tissues  would  become 
hotter  than  the  remainder,  and  might  possibly  burn  the 
smTOunding  parts  ;  and  if  a  very  strong  current  were  being 
employed,  the  wire  might  be  fused  at  either  of  these  points,  and 
thereby  interrupt  the  operation.  When  the  two  handles  are 
used,  and  the  wire  cannot  be  shortened,  those  portions  of  it  not 
embedded  in  the  tissues  should  be  carefully  watched,  and  not 
allowed  to  become  too  heated.  Their  temperature  may  be  kept 
down  and  the  operation  expedited  by  a  gradual  sawing  move- 
ment— that  is,  alternately  embedding  the  overlapping  part  of 
the  wire  in  the  growth  undergoing  removal. 

Advantages  and  Disadvantages  of  the  Galvano- 
cautery. — The  galvanic  has  several  advantages  over  Paquelin's 
and  all  other  forms  of  cautery.  The  instrument  can,  in  any 
case,  be  introduced  into  the  cavity  or  organ  or  along  the  passage 
leading  to  the  diseased  part  to  be  destroyed  or  removed,  and 
placed  against  that  part,  before  it  is  made  hot.  If  a  wii-e  loop 
be  used,  it  can  be  adjusted  round  the  growth  or  other  structm-e 
dehberately  and  carefully  before  the  cu'cuit  is  closed.  It  is 
therefore  particularly  applicable  for  the  destruction  of  un- 
healthy tissues  or  removal  of  growths  in  parts  difficult  of  access. 
Secondly,  the  amount  of  heat  can  be  regulated  and  its  action 
commenced  and  arrested  at  the  will  of  the  operator  or  by 
direction  to  his  assistant.  These  details  are  under  his  control 
in  a  manner  more  thoroughly  and  completel}^  than  with  an}" 
other  form  of  cautery  known  to  surgery.  Thirdly,  with  the 
galvano-eautery  there  is  no  bleeding,  for,  if  the  cauter  be  kept 
at  a  dull  red  heat  (about  600^  C),  hsemostasis  is  produced  at 
the  same  time,  in  the  case  of  a  heated  wire,  as  the  incision 
proceeds.  Fourthly,  there  is  a  singular  freedom  from  pain  after 
the  use  of  the  galvano-eautery  when  compared  with  opera- 
tions performed  with  the  ordinary  ecraseur  or  the  knife.  The 
extremities  of  the  severed  nerves  are  destroyed  by  the  bm-uing 
action,  and  the  trunks  are  protected  by  an  impervious  eschar. 
Lastly,  the  operation  is  itself  antiseptic,  and  the  eschar  which 
covers   the   wound   protects   it   and   renders   it    less   liable   to 


156  ELECTRICAI,    APPARATUS. 

piiruleut  infection  than  when  a  moist  and  granulating  surface 
is  left. 

The  disadvantages  of  galvano-cauteiy  are  that  the  batteries 
and  apparatus  are  expensive  and  reqmi-e  frequent  attention, 
otherwise,  when  wanted,  it  is  often  found  that  they  will  not 
work.  An  assistant  possessed  of  special  knowledge  and  skill 
is  almost  a  necessity,  whereas  with  the  actual  cautery  and 
PaqueHn's  thermo- cautery  the  help  of  any  intelHgent  indi\adual 
is  almost  sufficient.  "VVTien  electrolysis  can  be  used  instead  of 
galvano- cautery  a  second  person  is  not  always  required,  and  the 
objectionable  smell  of  burnt  animal  tissue  is  avoided.  This  is 
a  consideration  when  an  operation  takes  place  in  a  private 
house.  But  electrolysis  can  only  be  employed  for  the  destruction 
of  unhealthy  sm'f aces  or  the  treatment  of  tumom'S  by  interfering 
with  their  nutrition  ;  it  cannot  be  used  for  the  direct  removal 
of  growths :  hence  it  is  not  employed  so  much  in  definite 
siu'gical  operations — the  subject  of  this  manual — as  in  the 
treatment  of  diseases  of  women. 

The  Electric  Lamp. — A  small  electric  lamp  is  often  foimd 
most  useful  in  gynseeological  surgery  when  it  is  necessary  to 
employ  artificial  hght.  The  electric  light  can  be  held  upside 
do^TQ  or  in  any  position  that  will  prevent  it  from  casting  a 
shadow.  This  is  impossible  with  other  methods  of  Hghting 
when  the   hght  is  derived  from  a  flame.     The  electric  light 


Fk;.   73. — Small  ELECTiiic  Lamp.' 
(It  ])ears  a  niiiTor,  liut  tliis  is  seldom  requireil  for  iiteiiiu'  ami  vaginal  surgery.) 

can  also  be  introduced  into  the  vagina ;  and,  if  necessary,  the 
interior  of  the  uterus  itself,  after  dilatation  by  tents,  can  be 
lighted  up,  and  by  this  means  its  surface  may  be  examined. 
The  heat  evolved  is  very  trifling  and  not  sufficient  to  cause 
inconvenience.  The  lamp  (Fig.  73)  has  a  rheostat  concealed 
in  the  handle,  which  is  cylindrical  and  fluted  so  as  to  facilitate 
manipulation.  The  sliding  button  (a)  regulates  the  intensity 
of  the  hght  ;  by  this  means  also  the  circuit  can  be  made  and 


THE    ELECTRIC    LAMP.  157 

broken — that  is,  the  lamp  rendered  incandescent  and  extin- 
guished. The  mirror  at  the  end  is  not  required  when  the  lamp 
is  used  for  the   vagina   or   uterus.     An   independent  battery 


Fig.  74. — Electuic  Lamp  fitted  to  a  Fekgusson's  Speculum. 

composed  of  a  few  large  cells  is  u.sed  to  work  the  lamp,  which 
can  be  kept  incandescent  for  any  length  of  time  that  it  is 
likely  to  be  wanted  for  a  uterine  examination  or  operation. 


158 


CHAPTEE  YI. 

SURGICAL  PATHOLOGY  OF  CYSTIC  AND  ALLIED  DISEASES  OF 
THE  UTERINE  APPENDAGES.— EXAMINATION  OF  ABDOMINAL 
TUMOURS. 

Cystic  and  Allied  Diseases  of  the  Uterine  Appen- 
dages.— This  wide  subject  cannot  be  discussed  at  tength  in 
these  pages.  My  own  views  are  expressed  in  another  work,* 
where  I  have  recorded  a  large  number  of  cases  of  disease  of  this 
kind,  occurring  in  the  practice  of  myself  and  my  colleagues  at 
the  Samaritan  Hospital,  between  1877  and  1884.  I  shall  simply 
restrict  mj^self  to  an  enumeration  of  the  varieties  of  cystic 
and  allied  diseases  of  the  ovary,  tube,  and  broad  ligament, 
noting  the  chief  points  of  surgical  interest.  Of  these,  the 
presence  or  absence  of  a  pedicle  and  of  soHd  matter  is 
the  most  important.  The  dramngs  may,  I  trust,  aid  the 
operator  in  identifying  the  tumour  which  he  discovers  in  the 
com'se  of  an  operation,  and  in  understanding  its  nature  and 
relations. 

The  diagram  (Fig.  75)  Tvill  demonstrate  the  seat  of  origin  of 
each  variety  of  tumour,  as  well  as  the  position  and  relations  of 
the  different  jDarts  of  the  appendages  when  the  Fallopian  tube 
is  pulled  out  straight  (see  page  26) . 

The  varieties  of  cystic  and  allied  diseases  of  the  appendages 
likely  to  be  removed  by  abdominal  section  will  now  be  briefly 
tabulated. 

1.  Multilocular  Cystic  Tumour  of  the  Ovary. — 
Cystic  disease  of  the  ovary  proper,  common  ovarian  c^-st. 
Forms  a  multilocular  timiour,  one  cavity  generally  predomi- 
nating (Fig.  76).    The  loculi  may  contain  adenomatous  growths 

*  Clinical  and  Pathological  Observations  on  Tumours  of  the  Ovaiij,  Fallopian 
Tube,  aTid  Broad  Ligament.     1884. 


CYSTS    OF    THE    OYAItY    AND    BROAD    LIGAMENT. 


159 


Fig.  75. — Diagram  of  the  Stkuctures  ix  axd  adjacent  to  the  Broad 
Ligament.     {Author. ) 

1.  \a,  multilocular  cystic  tumour,  developed  iu  1,  parenchyma  of  the  ovary. 
3,  papillomatous  cystic  tumour  of  ovary  in  2,  tissue  of  hilum  of  ovary.  4,  simple 
broad  ligament  cyst,  independent  of  parovarium,  10,  and  Fallopian  tube.  5,  a 
similar  cyst  in  broad  ligament  above  tube,  but  not  connected  with  it.  6,  a 
similar  cyst  close  to  7,  ovarian  iimbria  of  tube.  8,  hydatid  of  Morgagni ;  this 
never  appears  to  form  a  large  cyst.  9,  cyst  developed  from  horizontal  tulje  of 
parovarium.  11,  cyst  developed  from  a  vertical  tube  ;  cysts  of  this  kind  form 
the  papillomatous  tumours  of  the  broad  ligament.  12,  13,  track  of  obliterated 
duct  of  Gartner  ;  pajHllomatous  cysts  are  said  to  be  developed  along  this  track. 


Fig.  76. — A  Small  Multilocular  Ovarian  Cyst.     {AutJior.) 


j'j,;   77 — Dermoid  Ova'.uax  Tumouk.  i;i;auixg  Teeth  axd  Bone.     {Author.) 
^. 


Fig.  78. — Dekmoid  Ovaiuax  Tcmouk,  coxsi.sting  of  Three  Loctli  of  veuy 

irregular  form. 

They  oiigiiiallj-  contiiined  sebaceous  matter.     {Museum  R.  C.  S..  Xo.  4,516.) 


CYSTS    OF    THE    OVARY    AND    BROAD    LIGAMENT. 


161 


Fluid  contents  glairy  and  albuminous,  of  high  specific  gravity, 
yellow  or  greyish  in  colour,  often  stained  with  altered  blood- 
pigment.     Grenerally  well  pedunculated.*      Seldom  malignant. 

2.  Dermoid  Ovarian  Tumour. — Same  seat  as  the  last 
variety.  Forms  a  tumour  with  few  loculi,  filled  with  hair, 
bone,  teeth  (Fig.  77),  sebaceous  matter,  liquid  fat,  etc.,  loculi 
lined  with  skin  or  anomalous  mucous  membrane.  Any  one  of 
the  contents  named  may  be  absent ;  hair  is  the  most  frequent. 
Sarcomatous  elements  frequent.  Gl-enerally  pedunculated. 
Dermoid  tiunom^s  may  assume  very  irregular  forms  (Fig.  78). 

3.  Papillomatous  Cystic  Tumour  of  the  Ovary. — 
Arises  in  the  tissue  of  the  hilum  (Fig.  75,  ,?,  J).  Almost 
imilocular,  cavity  containing  masses  of  papillomatous  or  cauli- 
flower   growths,     sometimes    scanty     (Fig.     79),     sometimes 


Fig.  79.^ — Papillomatous  Cystic  Tumouu  of  Ovary.     (AiifJior.) 

abundant.  Fluid  contents  generally  clear  and  watery,  of 
low  specific  gravity  and  free  from  albumen.  Pedicle  short, 
or  the  tumour  may  burrow  deeply  between  the  folds  of  the 
broad  ligament  (Fig.  79),  so  as  to  be,  in  some  cases,  absolutely 
sessile.  Papillomatous  growths  are  sometimes  found  in  the 
common  multilocular  form,  mixed  with  adenomatous  masses. 


*  By  the  term  pedunculated,  it  is  implied  that  a  pedicle  or  connecting  hand, 
suitahle  for  ligature,  clamp,  or  cautery,  exists  between  the  uterus  and  the  tumour. 


162 


DISEASES    OF    THE    UTERINE    APPENDAGES. 


4.  Papillomatous  Cystic  Disease  of  Broad  Liga- 
ment.— Always  sessile.  Grreat  tendency  to  infect  peritoneum. 
May  be  multilocular.  Cavities  contain  groTsiihs  and  fluid  as  in 
last  Tariety. 


\^^^^^*p^P^^  jj^ 


fi(j,  go. — Papillomatous  Dlsease  of  the  Broad  Ligamext.s,   completely 

HIDING   THE   APPENDAGES,    WHICH   CONTAIN   NO   CySTS. 

{Ihiseum  E.  C.  S..  Xo.  4,501.) 


Fig.  81.— Sp:ct[ox  of  an  Ovaky,  showing  its  suhface  covered  with 

Papillomata. 

It  contains  a  few  follicles.     {Museum  Fu  C.  S.,  Xo.  4,502.) 

5.  Free  Papillomatous  Disease  of  the  Broad  Liga- 
ment.— ]\Iasses  of  papillomata  infesting  the  uterine  append- 


CYSTS  OF  THE  OVARY  AND  BROAD  LIGAMENT. 


163 


ages  (Fig.  80),  often  covering  the  surface  of  the  ovary  (Fig.  81). 
Always  accompanied  with  abundant  peritoneal  effusion. 

Varieties  3,  4,  and  5  are  probably  developed  from  the  tubes  of 
the  Wolffian  body  in  the  hilum  and  parovarium. 

6.  Simple  Broad  Ligament  Cyst:  "Parovarian 
Cyst"  (Fig.  82). — Thin-waUed  cyst,  almost  invariably 
unilocular.  Fluid  contents  clear,  watery,  of  low  specific 
gravity,  and  non-albuminous.  Always  lies  between  the  layers 
of  the  broad  ligament  (Fig.  83),  with  the  Fallopian  tube  and 
its  fimbriae  greatly  stretched  over  its  surface.     It  is  generally 


Fig.  82. — Simple  Broad  Ligament,  or 
The  Ovary  has  been  laid  open. 


'Parovarian  Cyst. 
{Author. ) 


pedunculated,  as  it  does  not  usually  burrow  between  the  folds 
of  the  broad  ligament  as  far  as  the  uterus.  The  true  paro- 
varian origin  of  this  kind  of  cyst  is  questionable. 

7.  Papilloma  of  the  Fallopian  Tube  (Fig.  84).— 
Very  rare ;  may  be  pedunculated.  Fluid  contents  mucoid ; 
may  escape  from  the  ostium  of  the  tube  and  cause  peritoneal 
effusion.* 

8.  Enlargement  of  the  Hydatid  of  Morgagni.— This 
little  cyst-like  body  (Fig.  75,  8)  never  appears  to  reach  such  an 
extent  of  development  as  to  demand  operative  interference. 
The  same  is  the  case,  except,  possibly,  in  a  few  rare  instances, 

*  See  Author,  Transactions  of  the  Ohstctrical  Society  of  Lomlon,  vol.  xxviii.,  1886. 


164 


DISEASES   OF    THE    UTERINE    APPENDAGES. 


with  simple  broad  ligament  cysts  develoiDed  above  tbe  tube  (Fig. 
7,  page  22). 

Solid   Tumours    of  the    Ovary.— These   growths    are 
developed  in   the   same    anatomical    region   as    the    common 


Fig.  83.— Dissection  of  Broad  Lioamknt,  to  show  its  uelatioxs  to 

TWO    (_'YSTS. 

The  ovary  lies  to  the  left.  One  layer  of  the  broad  ligament  is  partly  divided 
to  show  the  smaller  cyst,  and  is  turned  up  below  to  expose  part  of  the  wall  of  a 
large  cyst,  which  has  lieen  almost  entirely  cut  away.  The  Fallopian  tube  (the  outer 
part  of  which  has  a  black  rod  inserted  into  its  cut  extremity,  and  hangs  at  a 
right  angle  to  the  inner  part)  had  been  stretched  over  the  surface  of  the  lai'ge 
cyst.     {Museum  R.  C.  S.,  No.  4,588.) 

multilocular  cyst,  and  hence  are  generally  pedunculated.     The 
commonest  forms  are  fibroma,  sarcoma,  and  carcinoma.     The 


SOLID    OVARIAN   TUMOURS ABDOMINAL    TUMOURS. 


165 


more   malignant   types   grow   very   rapidly,    and   ascites    and 
anasarca  tend  to  develop  early. 


EiG.  84. — Papilloma  of  the  Fallopian  Tube. 
The  tube  has  been  laid  open,  showing  the  papillomata.     A  bristle  passes  into 
the  tube,  through  the  growths  and  out  at  the  ostium  below.     The  ovary,  small 
and  flattened,  lies  to  the  left,     {llusnmi  E.  C.  S.,  No.  4,584.) 


TSWfSSn. 


G.  85. — A  Small  Saecomatoits   Ovary  {natural  size),  removed  avith  it.s 
fellow,  avhich  formed  a  large  solid  tumour,  during  life. 
{Museum  R.  C.  S.,  No.  4,533.) 


EXAMINATION   OF   ABDOMINAL   TUMOURS. 

Diagnosis. — Tlie  general  rules  for  diagnosis  of  abdominal 
tumonrs  are  given  in  all  the  standard  text-books  on  medicine 
and  surgery.  Perhaps  the  most  systematic  treatise  on  ex- 
ploration of  the  abdomen  is  the  late  Dr.  Murchison's  Clinical 
Lectures   on   Diseases   of  f/ie    Liver,    Jaundice,   and  Ahdominal 


166  EXAMINATION    OF    ABDOMINAL   TUMOURS. 

Drojysij.  Eveiy  surgeon  who  desires  to  perform  abdominal 
section  should  study  it.  Whilst  what  is  technically  known  in 
oui-  profession  as  sound  "  medical "  knowledge  is  needed,  a 
familiarity  with  the  anatomy  and  pathology  of  the  female 
organs  is  equally  necessary  for  our  purpose.  In  short,  the 
sm'geon  must  imderstand  ease-taking,  the  "medical"  aspects  of 
abdominal  disease,  and  the  science  and  art  of  gynaecology  as 
well,  when  he  undertakes  operations  for  the  removal  of  ovarian 
and  uterine  tumours,  or  otherwise  diseased  pelvic  structures. 

Diagnosis  is  always  liable  to  fallacy.  Abdominal  swellings 
are  covered  by  the  abdominal  walls.  If  some  objects  looking 
like  a  knife,  a  watch,  and  a  small  book,  lie  under  a  cloth,  we 
lift  up  the  cloth  to  make  sure  of  the  nature  of  the  hidden 
objects,  though  to  endeavour  to  discover  their  nature  by  placing 
the  hand  on  the  cloth  may  exercise  our  sense  of  touch.  In 
the  above  facts  he  some  of  the  first  principles  of  abdominal 
surgery. 

Thus  we  feel  the  abdominal  walls  to  ascertain  the  nature 
of  a  tumom-,  but  we  never  forget  that  the  evidence  of  our 
hands  may  be  most  untrustworthy.  It  is  not  always  advisable 
to  make  exploratory  incisions,  nor,  indeed,  does  any  sm-geon 
ever  make  them  without  some  preliminary  physical  examina- 
tion of  the  abdomen  and  pelvis.  On  the  other  hand,  these 
incisions  prove  what  palpation  may  never  prove.  Hence,  ex- 
perienced operators  often  become  very  sceptical  about  even 
their  o-um  diagnostic  powers,  and  rely  on  exploratory  operations 
rather  than  physical  examination  of  the  abdomen. 

Many  surgeons  object  to  such  expressions  as  a  "  minor 
operation,"  or  "just  a  whiff  of  chloroform."  They  are  right, 
for  self-evident  reasons.  I  believe  that  it  is  equally  ■svT.-ong  to 
say  that  we  are  "  onh/  going  to  examine  the  case."  Sounds 
may  be  necessary  evils,  but  e^Hds  they  certainly  are.  Simple 
percussion  and  digital  exploration  of  the  vagina  are  not 
always  unattended  with  risk.  Experienced  operators  at  special 
hospitals  certainly  owe  some  of  their  triumphs  to  the  freedom 
of  patients  from  repeated  examinations.  I  will  conclude  these 
preliminary  observations  by  briefly  summarizing  them.  The 
surgeon  must  diagnose  carefully,  but  must  not  consider  that 
the  process  of  diagnosis  is  certain  or  void  of  danger  to  the 


EXAMINATION    OF    ABDOMINAL   TUMOURS.  167 

patient.  He  may  teach,  but  not  at  the  patient's  expense. 
lie  must  not  have  recourse  too  frequently  to  exploratory 
incisions,  but  must  not  fear  to  make  them  when  diagnosis  is 
obscure,  yet  the  existence  of  tumours  evident. 

Case  Taking. — The  surgeon  should  always  take  his  own 
case,  though  an  assistant  may  write  down  the  patient's  name, 
address,  and  other  details  of  the  kind.  A.  set  of  case  books, 
ready  printed,  should  be  kept  in  the  ward.  Sir  Spencer  Wells' 
case  book  is  well  known.  Case  books  may  be  printed  at  a 
small  expense,  each  forming  a  small  octavo  pamphlet,  with 
headings  on  each  page,  as  follows  : — 

1.  Number — Date  of  first  visit — Name — Age — Condition — 
Occupation — Residence — Number  of  children — Last  confine- 
ment— Abortions — Mammary  Areolse — G-eneral  appearance — 
Medical  attendant  (before  admission). 

2.  Greneral  examination  of  abdomen :  Inspection,  palpation, 
percussion,  and  auscultation. 

3.  Outline  sketch  of  abdomen.  Below  spaces  to  fill  in 
measurements  (three  columns  will  be  sufficient,)*  under  head- 
ings :  Grirth  at  umbilical  level — Ensif  orm  cartilage  to  umbilicus 
— umbilicus  to  symphysis  pubis — Right  anterior  superior  spine 
of  ilium  to  umbilicus — Left  ditto  to  umbilicus. 

4.  Pelvic  examination — Outline  sketch  of  vertical  section 
of  pelvis,  showing  sacrum,  symphysis  pubis,  anus,  perineum, 
lower  part  of  vagina,  and  urethra  (the  internal  organs  should 
not  be  drawn) — Grenerative  system  (catamenial  history) — 
Urinary  system. 

5.  Digestive  system — Respiratory  ditto  (including  tempera- 
ture)— Circulatory  ditto — Nervous  ditto — History  before  ap- 
pearance of  tumom". 

6.  History  of  patient  and  disease. 

7.  Tapping  or  exploratory  puncture — Diagnosis. 

8.  Operation.  Date — Place — Nurse's  name — Assistants 
and  visitors — Ansesthetic — Antiseptic  employed — Details  of 
operation. 

9.  Details,  continued. 

*  Thus,  in  the  case  of  a  slow-gi'owing  tumour,  the  abdomen  may  be  measured 
at  least  twice,  first  at  the  patient's  residence  or  in  the  out-patient  department 
of  a  hospital,  and  afterwards  a  few  days  before  operation  is  contemplated. 


168  EXAMINATION    OF    ABDOMINAL    TUMOURS. 

10.  Details,  continued — Description  of  tmnour  ;  its  weiglit; 
fluid  removed. 

11 — 18  or  20.  Tables  for  "  After  Treatment  and  Progress," 
with  headings — Date — Hour — Condition,  diet,  and  prescriptions 
— Temperature — Pulse — Respiration. 

Lastly,  three  or  four  pages  for  "  Subsequent  History." 

The  above  may  be  printed,  so  as  to  be  bound  up  with  ward 
registrar  books,  or  carried  about  separately,  after  use,  as  may 
be  required. 

Treatment  of  Patient  during  Physical  Examina- 
tion of  Abdomen. — The  patient  must  remove  her  drawers, 
let  down  the  upper  border  of  the  skirt  and  petticoats  as  low  as 
the  pubes,  and  raise  her  underclothing,  so  that  the  surface 
of  the  abdomen  may  be  exposed  thoroughly,  and  exploration 
of  the  pelvic  organs  may  be  facilitated  at  the  same  time. 
The  stays  had  better  be  taken  off  entirely.  Then  the  patient 
is  placed  upon  her  back  on  a  couch,  with  her  knees  drawn  ilp, 
and  her  head  and  shoulders  raised,  so  that  she  may  lie  at 
perfect  ease.  The  least  discomfort  may  cause  contractions 
of  the  recti,  so  that  care  must  be  taken  that  the  pillows 
or  cushions  supporting  the  shoulders  and  knees  are  well- 
arranged  and  do  not  slip  away.  It  is  always  best  if  the 
patient's  bowels  have  been  cleared,  as  scybala  seriously  inter- 
fere with  examination  of  the  pelvic  viscera.  When  scybala  are 
detected,  it  is  advisable  to  repeat  the  examination  after  they 
have  been  removed  by  enemata. 

The  room  in  which  the  patient  is  examined  should  be  warm, 
and  not  adjacent  to  a  noisy  street  or  to  a  room  full  of  people 
engaged  in  conversation.  A  draught  causes  real  danger  to 
the  patient ;  cold  is  the  source  of,  not  only  discomfort,  but 
also  great  phj^sical  irritability,  impeding  diagnostic  manipu- 
lations. Noise  is  disturbing  to  the  surgeon,  and  a  grave 
impediment  when  pregnancy  is  suspected,  for  then  auscul- 
tation must  be  practised,  in  order  to  find  out  if  the  foetal 
heart-soimds  be  audible,  and,  therefore,  perfect  silence  is 
essentially  requisite.  The  surgeon  must  be  particularly  care- 
ful that  his  hands  are  warm  and  his  nails  short.  Cold 
fingers  cause  contractions  of  the  patient's  abdominal  muscles, 
and  do   not  possess  so  perfect  a  degree  of  tactile    sensibility 


PHYSICAL    EXAMINATION    OF    THE    ABDOMEN.  169 

as  when  warm.  Tight-fitting  gloves  should  not  be  worn  by 
a  surgeon  about  to  examine  an  abdominal  case  ;  they  greatly 
impair  the  sensibility  of  the  fingers.  The  best  way  to 
restore  warmth  to  cold  hands,  when  it  is  too  late  to  take 
exercise,  is  to  wait  in  a  warm  room  a  few  minutes  before 
examining  the  case.  The  surgeon  will  find  his  pockets  to  be 
good  receptacles  of  caloric  for  use  on  such  occasions. 

The  examination  must  be  carried  on  with  great  gentleness. 
The  process  is  often  fatiguing,  and  is  apt  to  try  short  tempers. 
The  patient,  it  must  never  be  forgotten,  is  a  patient  as  well 
as  a  case.  Some  patients  will  display  fear,  ill-temper,  or  signs 
of  want  of  confidence  in  the  surgeon.  The  word  "  only,"  or 
any  synonymous  word  or  expression,  must  never  be  used  with 
regard  to  the  examination  as  such,  just  as  it  is  inadvisable  in 
speaking  of  many  other  matters  relating  to  medical  subjects. 
I  have  heard  a  patient  complain  seriously  of  a  surgeon  who 
said  to  her,  "  This  is  only  the  examination,  not  the  operation.'''' 
Such  a  speech  is  the  height  of  bad  taste,  and  betrays  great 
ignorance  of  human  nature,  and  disregard  of  a  patient's  feel- 
ings. It  is  thus  read  by  the  patient :  "I  am  suspected  to  be 
the  subject  of  a  serious  disease,  and  the  doctor  is  '  only,'  as 
he  calls  it,  subjecting  me  to  a  disagreeable  process  in  order 
to  find  out  if  he  cannot  cure  me  by  performing  a  dangerous 
operation."  To  understand  this  interpretation  in  full,  the 
surgeon  must  bear  in  mind  what  sense  the  words  "  disease," 
"  examination,"  and  "  operations  "  convey  to  persons  outside 
our  profession — above  all,  when  they  are  patients.  The  objec- 
tionable expression  which  is  quoted  above  is  meant  to  be  re- 
assuring, but  many  well-meant  words  hurt  people's  feelings. 
What  should  be  said  is,  "I  am  not  going  to  perform  any 
operation  at  present,  but  it  is  necessary  that  I  should  examine 
you."  The  patient  must  never  be  contradicted  when  she  com- 
plains that  the  manipulations  give  pain. 

Next  to  the  patient's  feelings  in  general,  the  particular  state 
of  her  mind  at  the  moment  of  examination  must  be  taken  into 
account.  She  is  thinking  of  nothing  but  her  case,  of  course, 
and  is  apprehending  pain  from  the  manipulations  of  the 
surgeon.  This  apprehension  causes  a  characteristic  expres- 
sion.    The  teeth  are  usually  clenched,  and  the  limbs  more  or 


170  EXAMINATION    OF    ABDOMINAL   TUMOURS. 

less  rigid.  The  patient  has  a  tendency  to  stretch  her  hands 
towards  those  of  the  surgeon,  to  place  them  over  a  tender 
spot  as  if  to  keep  him  from  touching  it,  and  perhaps  to  catch 
hold  of  his  wrists.  This  is  very  trying  to  the  surgeon,  and 
it  must  he  rememhered  that  all  the  above  signs  of  mental 
perturbation  are  most  frequent  in  the  more  obscure  cases  of 
abdominal  tumotir,  especially  when  there  have  been  inflam- 
matory complications. 

To  counteract  these  inconveniences,  the  surgeon  must  re- 
assure the  patient,  and  it  is  quite  allowable  for  him  to  divert 
her  attention  by  talking  of  some  subject  not  relating  to  her 
case.  The  effect  of  this  judicious  measure  must  be  familiar 
to  most  surgeons  and  physicians.  Thus  the  surgeon  may  lay 
his  right  hand  upon  an  abdomen  where  the  recti  are  so  tense 
that  he  feels  almost  inclined  to  believe  that  there  must  be  a 
solid  tumour,  with  intestines  adherent  in  front  to  account  for 
the  resonance.  He  inquires  about  the  appetite,  the  catamenia, 
and  other  professional  matters,  and  the  tenseness  will  pro- 
bably persist.  Yet  if  he  suddenly  should  ask  the  patient  if 
the  weather  agree  with  her,  or  if  the  place  she  comes  from 
be  cold  in  winter,  it  is  highly  probable  that  the  recti  will 
immediately  collapse,  and  the  surgeon's  hand  may  even  be 
brought  in  contact  with  the  promontory  of  the  sacrum,  or  the 
lumbar  vertebrse. 

The  clenching  of  the  teeth,  associated  as  it  is  mth  irregular 
respiration,  is  to  be  counteracted  by  asking  the  patient  to  keep 
her  teeth  apart,  and  not  to  hold  her  breath.  Her  hands  should 
be  folded  across  her  chest. 

Among  other  general  considerations,  the  surgeon  must  re- 
member that  healthy  structures  may  be  tender  as  well  as 
regions  which  are  the  seat  of  disease,  that  hard  pressure  on 
any  structure  causes  pain,*  and  that  rapid  manipulations,  even 
if  gentle,  frighten  a  patient.  The  nails  are  often  the  cause 
of  trouble  in  these  examinations.     I  have  seen  a  surgeon  with 

*  The  reader  must  have  met  with  members  of  the  profession  vrho  seem  to  think 
that  a  part  must  be  diseased  because  squeezing  or  pressing  it  hard  causes  pain. 
A  boy's  ear  is  not  diseased  because  it  smarts  when  it  is  boxed.  See  also  my 
observations  on  pressure  of  the  sacral  nerves  in  pelvic  exploration,  page  49.  I 
have  already  spoken  against  the  practice  of  contradicting  patients  who  complain 
of  pain  during  examination  (pages  47,  169), 


PHYSICAL    EXAMINATION    OF    THE    ABDOMEN.  171 

his  left  hand  on  a  patient's  abdomen  and  his  right  forefinger 
in  the  vagina,  wondering  why  a  small  tumour  was  "  so  pain- 
ful." The  pain  was  really  caused  by  the  nail  of  the  fore- 
finger pressing  against  the  vaginal  mucous  membrane,  and 
the  nails  of  the  left  fingers  pressing  into  the  abdominal  in- 
teguments. This  latter  bit  of  clumsiness,  annoying  to  patient 
and  surgeon,  even  if  not  misleading,  is  very  likely  to  occur 
when  deep  pressure  is  made  on  lax  abdominal  walls,  for  the 
integuments  bulge  beyond  the  fingers  and  press  against  the 
nails.  Though  the  nails  must  not  be  turned  down,  the  op- 
posite extreme  of  holding  the  fingers  too  stiffly  must  be 
avoided. 

During  inspection,  linese  albicantes  and  hernial  protrusions 
must  be  taken  into  account,  as  well  as  other  appearances 
which  force  themselves  on  the  surgeon's  observation,  such 
as  oedema,  enlarged  veins,  and  prominence  in  the  flanks  or 
front  of  the  abdomen.  The  experienced  may  learn  a  great 
deal  from  inspection  alone.  Percussion  should  be  commenced 
below  the  umbilical  region,  and  not  over  the  transverse  colon 
or  stomach,  for  the  tympanitic  resonance  there  may  dull  the 
ear  for  less  marked  resonance  elsewhere.  The  left  hand  must 
be  kept  perfectly  yet  gently  applied  to  the  abdominal  walls 
during  the  process,  for  if  the  knuckles  go  up  and  the  points 
of  the  fingers  press  unduly,  there  may  be  a  space  between 
the  fingers  and  the  abdomen  at  the  point  where  the  former 
are  tapped,  and  this  will  affect  the  resonance ;  moreover,  there 
will  be  danger  of  running  the  nails  into  the  integuments. 
In  percussing  each  fiank,  the  surgeon  should  stand  on  the 
opposite  side,  as  it  is  not  easy  to  keep  the  hand  properly 
applied  to  the  flank  on  the  same  side. 

Lastly,  vaginal  digital  exploration  (or  rectal,  as  a  rule,  in 
virgins)  must  never  be  omitted  as  part  of  the  process.  With- 
out bimanual  examination  it  is  often  impossible  to  tell  the 
relations  of  a  tumour  to  the  pelvic  viscera.  Careful  exploration 
of  the  cervix  should  be  made  before  the  sound  is  introduced, 
independently  of  all  other  precautions.  Surgeons  are  liable 
to  be  misled  by  assuming  that  only  young  and  attractive  women 
€an  become  pregnant  when  single,  and  can  tell  falsehoods  about 
the  catamenia.     I  know  of  a  remarkable  case  where  a  surgeon. 


172  EXAMINATION    OF    ABDOMINAL   TUMOURS. 

after  examining  tlie  abdomen  of  a  single  woman  about  forty- 
seven  years  old,  wbo  declared  tbat  she  was  regular,  passed  a 
sound  into  ber  uterus,  remarking  at  tbe  time  bow  soft  the 
cervix  felt.  A  gusb  of  fluid  followed,  and  tben  it  struck  tbe 
surgeon  tbat  tbere  migbt  be  a  foetus  in  tbe  uterus,  wbicb 
proved  to  be  tbe  case.  Tbe  patient  confessed  tbat  sbe  bad 
lied  about  ber  catamenia.  I  once  assisted  at  an  operation  wbere 
tbe  patient,  a  very  plain  single  woman,  aged  tbirty-five,  bad 
been  bedridden  for  a  year  witb  a  large  fibroid  tumour  of  tbe 
uterus.  In  removing  tbe  tumour,  a  foetus  of  about  tbe  sixtb 
week  was  discovered.  No  soimd  bad  been  passed  nor  bad  tbe 
cervix  been  examined  for  a  long  time. 

Erroneous  Diagnosis  after  Abdominal  Examina- 
tion.— I  bave  already  noted  some  of  tbe  cbief  sources  of 
fallacy.  Tbe  surgeon  is  not  likely  to  forget  tbat  be  may  err, 
tbat  a  leading  authority  wbom  be  consults  may  be  wrong  whilst 
be  himself  is  in  tbe  right,  and  tbat  the  youngest  student  may 
diagnose  what  bis  elders  have  overlooked  or  failed  to  under- 
stand. Putting  aside  any  further  considerations  of  this  kind, 
I  will  now  classify  the  chief  sources  of  error  in  diagnosis  of 
suspected  abdominal  tumours. 

1.  Preconceived  Ideas. — The  surgeon,  examining  witb  the 
fixed  idea  tbat  there  must  be  a  tumour  of  some  kind  or 
other,  is  apt  to  mistake  rigid  abdominal  walls,  tympanitic 
intestines,  or  a  distended  bladder  for  a  tumour.  He  may  dwell 
too  much  on  the  probability  tbat  a  tumour,  which  really  exists, 
is  ovarian. 

2.  Over-confidence  in  a  Patienfs  History. — This  is  tbe  most 
frequent  source  of  tbe  awkward  or  even  perilous  error  of  mis- 
taking a  pregnant  uterus  for  a  tumour  (see  page  171).  Not  only 
must  all  cases  of  abdominal  swelling  in  young  single  women  be 
considered  independently  of  the  history,  but  the  surgeon  must 
also  distrust  the  opinion  of  married  women  who  bave  bad 
many  children.  Experience  causes  these  respectable  members 
of  society  to  believe  in  themselves  too  much.  When  a  patient 
of  this  class  says  that  she  cannot  be  pregnant^  the  surgeon  must 
ask  ber  why  she  holds  that  opinion.  One  reply  will  be  that 
sbe  knows  when  sbe  is  pregnant  by  ber  bodily  feelings.  As 
tbe  prime  of   hfe  advances,  however,  these  general  sensations 


ERRONEOUS    DIAGNOSIS    AFTER   ABDOMINAL    EXAMINATION.    173 

tend  to  disappear,  and  tlie  patient  may  be  thrown  off  her 
guard.  I  have  known  a  case  of  pregnancy  mistaken  for 
ovarian  disease  through  neglect  of  this  fact.  Again,  scanty 
menstruation  may  be  overlooked,  or  amenorrhoea  may  pre- 
cede conception ;  then  the  patient  or  surgeon  may  overlook 
pregnancy  because  there  has  been  amenorrhoea  for  over  nine 
months.  In  this  way  I  have  known  cases  of  normal  and  of 
extra-uterine  pregnancy  to  be  attributed  to  ovarian  tumour. 
On  the  other  hand,  a  swelling  said  to  have  been  detected 
ten  months,  a  year,  two  years,  or  even  longer,  before  the 
date  of  examination,  may  have  been  originally  simple  obesity 
or  flatulence.  Pregnancy  supervening,  the  enlarged  uterus  may 
naturally  be  mistaken  for  a  morbid  growth. 

3.  Omission  of  Precautions. — Certain  measures  are  of  diagnostic 
value  as  well  as  being  necessary  steps  in  preparation  for  an 
operation.  Thus  neglect  of  the  use  of  the  catheter,  on  one 
occasion,  nearly  led  to  a  distended  bladder  being  tapped.  A 
loaded  rectum  should  always  be  emptied  before  a  thorough 
examination  is  made.  I  once  examined  a  case  where  a  sig- 
moid flexure,  loaded  with  scybala,  had  been  taken  for  a  dermoid 
ovarian  tumour. 

4.  Faulty  Palpation  and  Percussion. — The  art  of  palpation 
and  percussion  is  never  thoroughly  learnt  or  understood  by 
many  medical  practitioners  of  fair  experience.  The  tips  only 
of  the  fingers  may  be  applied  to  the  abdominal  walls;  this 
causes  the  recti  to  contract,  as  the  nails  irritate  the  integu- 
ments, thus  a  solid  or  cystic  tumour  may  be  diagnosed.  On 
percussing,  if  the  fingers  be  not  applied  to  the  abdomen  along 
their  entire  length,  a  dull  sound  may  be  produced.  This  fact 
can  be  proved  at  once  by  pressing  the  ends  of  the  fingers 
only  against  a  resonant  part  of  the  abdomen  and  percussing 
them  high  up,  where  they  do  not  touch  the  integument;  no 
resonance  can  then  be  elicited. 

5.  Real  Difficulties. — There  remain  difiiculties  which  de- 
pend entirely  on  the  nature  of  the  case.  A  complicating  or 
coincident  malady  may  mask  the  presence  or  nature  of  a 
tumom-.  A  cyst  already  detected  may  burst  before  a  second 
examination.  Skill,  care,  and  experience  can  alone  guard  the 
surgeon  from  errors  which  these  difiiculties  may  cause. 


174  EXAMINATION    OF    ABDOMINAL    TUMOURS. 

Diagnosis  of  Tumours  and  Abdominal  Distensions. 

— It  is  not  possible  for  me  to  describe  at  length,  the  principal 
conditions  which  more  or  less  resemble  ovarian  tumoiu-s  or  other 
diseases  of  the  female  organs,  which  may, be  cured  by  operations 
allied  to  ovariotomy.  I  shall  simply  tabulate  these  conditions, 
for  by  so  doing  I  may  possibly  aid  the  surgeon  who  has  a 
case  in  hand  which  is  likely  to  require  abdominal  section. 

Class  I. — A  Tumour  or  Tumours  more  or  less  Distinct. 

1.  A   Central   Tumour,  distending  lower  part    of 
Abdomen. 

A.  Freeh/  fluctuating. 

Ovarian  cyst,  with  one  cavity  greatly  predominating 

over  the  others. 
Broad  ligament  cyst. 
Encysted  di'opsy  of  peritoneum. 
Distended  bladder. 
Hydramnios. 

B.  Fluctuating  in.  parts. 

Ovarian  cyst,  multilocular. 
Ovarian  cyst  with  much  solid  matter. 
Fibro-cystic  uterine  tumour. 
Pregnancy  (later  stages). 

C.  Solid,  no  fluctuation. 

Solid  ovarian  tumour. 
Fibroid  uterine  tumour. 
Pregnancy  (earlier  stages). 

2.  A  Tumour  distending  lower  part  of  Abdomen, 
not  central  in  position. 

•    A.  Fluctuating. 

Penal  cyst  or  retro-peritoneal  cyst  in  the  neighbom*- 

hood  of  the  kidney. 
Cyst  of  omentum  or  mesentery. 
Hydrosalpinx  (extreme  cases). 
Ovarian  cyst  (rare). 
Cvst  in  abdominal  walls. 


DIAGNOSIS    AND    CHARACTERS    OF    TUMOURS.  175 

B.   Solid. 

Extra -uterine  pregnancy  (tumour  may  be  central). 
Scybala  in  caecum  or  sigmoid  flexure. 
Enlarged  spleen  (extreme  cases). 

3.  Two  or  more  Tumours  distending  lower  part  of 
Abdomen. 

Bilateral  ovarian  tumom-s  (especially  small  dermoid 

cysts) . 
Multiple  subperitoneal  uterine  fibroids. 
Hydatid  disease  of  peritoneum. 

Class  II. — Abdomen  Distended  ;  no  Distinct  Tumour. 

1.  Fluctuation  distinct. 

Ascites  (all  cases,  including  those  where  an  ovarian  or 
other  tumour  may  exist) . 

2.  No  Fluctuation. 

Tympanites  and  phantom  tumour. 

Obesity. 

Pendulous  abdomen. 

The  above  table  does  not  include  tumoui^s  purely  pelvic, 
tumours  evidently  confined  to  the  upper  part  of  the  abdo- 
men, and  tumours,  cysts,  and  abscesses  in  the  inguinal  and 
lumbar  regions. 

Physical  and  Clinical  Characters  of  Ovarian  Cystic 
Tumours. — This  subject  is  treated  at  length  in  the  standard 
works  of  Spencer  Wells,  Olshausen,  Tait,  Peaslee,  Atlee,  and 
other  writers,  and  does  not  come  within  the  immediate  scope 
of  this  work.  At  the  same  time,  it  should  be  understood 
that  the  surgeon  must  not  think  of  operating  unless  he  feels 
that  he  possesses  a  fair  knowledge  of  the  main  distinctions 
between  ovarian  tumours,  uterine  tumours,  and  other  diseases 
which  cause  distension  of  the  abdomen,  and  may  prompt  him 
to  perform  abdominal  section.  The  use  of  the  sound,  with 
every  precaution  (page  74),  is  especially  necessary  for  dia- 
gnosis between  ovarian  cysts  and  soft  uterine  myomata,  but 
this  diagnosis  cannot  be  confirmed  by  rough  and  ready  rules. 


176 


EXAMINATION    OF    ABDOMINAL    TUMOURS. 


since  the  sound  may  move  wlien  tlie  tumour  is  moved  in 
some  cases  of  ovarian  cyst  with  a  short  pedicle ;  and  there 
are  other  sources  of  fallacy  attendant  on  the  use  of  that  in- 
strument. The  inexperienced  are  recommended  to  study,  at 
least,  any  standard  British  text-book  on  diseases  of  women 
before  undertaking  ovariotomy. 

There  is  seldom  any  difficulty  in  diagnosing  a  case  of  multi- 
locular  cystic  tumour  of  the  ovary,  free  from  certain  compli- 
cations ;  on  the  other  hand,  there  remain  comphcations  not  at 
all  easy  to  discover  without  opening  the  abdominal  cavity,  and 
some  of  these  complications  may  obscure  diagnosis,  and  cause 
the  wisest,  most  experienced,  and  most  practical  surgeon  to  err. 
In  the  chapters  on  the  Operation  of  Ovariotomy,  I  shall  speak 
of  what  some  may  term  unexpected  conditions  discovered 
during  an  abdominal  section,  though,  strictly  speaking,  the 
operator  should  be  careful  not  to  be  taken  by  surprise,  and 
should  be  ready  to  expect  any  possible,  though  improbable, 
morbid  condition,  other  than  cystic  ovarian  disease. 


Yia.  86. — A  Twisted  Pediclk,  attached  to  a  small  portion"  of  very 
THICK  CYST-WALL.      {Museum  R.  C.  8.,  No.  4,550a.) 

The  surgeon  must  note  the  purely  clinical  featui'es  of  the 
case,  especially  high  temperature,  and  histories  of  sudden  attacks 
of  pain,  or  constant  local  suffering,  or  of  sudden  diminution  in 
the  size  of  the  tumour.  Lives  have  been  saved  by  removing 
suppurating  cysts,  and  by  operating  in  cases  of  gangrene  of  an 


TWISTED    PEDICLE TAPPING.  177 

ovarian  tumour,  from  twisting  of  the  pedicle.  As  a  rule,  how- 
ever, this  peculiar  condition  simply  causes  dull  constant  pain, 
with  a  cessation  of  the  growth  of  the  tumour.  At  operation,  the 
pedicle  is  often  found  toasted  spirally,  two  or  three  tui'ns,  as  in 
Fig.  86,  The  vessels  are  generally  blocked  ;  sometimes  they  are 
dilated  as  in  Fig.  87,  when  they  present  a  remarkable  appear- 
ance, as  though  a  large  marble  lay  in  the  pedicle.  When  the 
pedicle  is  completely  atrophied,  and  the  cyst  has  become 
detached  and  receives  its  nourishment  from  adhesions,  as  will  be 
noted  in  the  chapters  on  Ovariotomy,  the  case  will  puzzle  the 


Fig.  87. — Dilated  Vein  from  a  Twisted  Pedicle. 

The  dilatation  lias  been  laid  open.     An  artery,  perfectly  impervdons,  adheres  to 
the  vein  posteriorly. 

operator.  On  the  other  hand,  when  the  pedicle  is  twisted,  and 
no  adhesions  exist,  the  operation  is,  as  a  rule,  particularly  easy 
and  safe.  Twisted  pedicle  is  very  common  in  dermoid  ovarian 
disease. 

Tapping  for  Diagnosis. — Some  authorities  strongly 
advocate  tapping  for  diagnostic  purposes.  They  assert  that 
the  fluid  thus  withdi-awn  can  be  examined;  that  the  tumour 
may  be  "  parovarian  " — that  is,  a  simple  broad  ligament  cyst 
cm-able  by  tapping  ;  that  it  can  be  proved  by  tapping  whether 
the  tumour  be  suitable  for  operation ;  and  lastly,  that  tappino- 
can  do  no  harm,  and  is  safer  than  operation. 

Long  experience  has  led  me  to  consider  that  these  ideas  are 
more  or  less  fallacies,  even  when  aspiration  is  meant,  rather  than 
simple  tapping  with  a  trocar.  The  fluid  may  be  examined, 
certainly,  but  in  doubtful  cases  little,  if  anything,  may  be  proved 
by  examination  of  the  fluid.     The  thick,  greasy  fluid  contents 

N 


178  EXAMINATION    OF    ABDOMINAL    TUMOURS. 

of  dermoid  and  old  cystic  tumours  will  often  fail  to  pass 
through  an  aspirating  needle.  In  dermoid,  malignant,  and 
papillomatous  tumours,  some  of  the  secondary  cysts  may  contain 
common  ovarian  fluid,  others  the  clear  fluid  of  broad  ligament 
cysts  :  the  puncture  of  one  cyst  would  thus  lead  to  false  con- 
clusions. Tapping  cannot  prove  that  the  tumour  is  a  simple 
broad  ligament  cyst.  I  have  seen  clear,  waterj^  fluid  in  the 
most  malignant  papillomatous  cysts.  Aspiration  of  such 
cysts  may  cause  severe  haemorrhage  from  the  vascular  villous 
masses  which  fill  them.  The  argument  that  tapping  may  cure 
a  broad  ligament  cyst  will  receive  further  comment.  Tapping 
•can  never  prove  that  a  tumom-  is  suitable  or  unsuitable  for 
operation,  it  can  seldom  verify  malignancy,  which  it  may  often 
overlook,  and  can  settle  httle  or  nothing  about  adhesions  or  the 
natm^e  of  the  pedicle.  The  worst  doctrine,  in  regard  to  tapping, 
is  that  it  can  do  no  harm.  It  involves  the  risk  of  haemorrhage, 
.and  the  escape  of  foetid  or  purulent  fluid,  sarcoma  or  cancer 
'Cells  into  the  peritoneal  canity.  Metastatic  deposits  of  common 
glandular  intracystic  growths  are  well-known  and  very  serious 
complications ;  they  can  certainly  be  set  up  by  exploratory 
punctures.  In  cases  where  there  is  a  suspicion  that  the  tumour 
may  be  a  cystic  fibroid  of  the  uterus,  should  that  suspicion  be 
■correct,  tapping  would  involve  great  danger,  as  wounded  uterine 
iissue  often  bleeds  uncontrollably. 

Tapping  is,  however,  allowable  in  cases  where  the  patient  is 
suffering  from  some  inter-current  malady,  such  as  bronchitis, 
which  must  be  cured  before  operation  ;  the  presence  of  a  bulky 
tumour  adds  to  the  patient's  sufferings,  and  retards  recovery. 
"When  the  patient  is  subject  to  great  anasarca  of  the  legs,  with 
ascites,  and  the  presence  of  an  ovarian  tumour  is  strongly 
suspected,  tapping  will  relieve  the  complications  just  mentioned  ; 
then  manual  exploration  of  the  abdomen  and  pelvis  will  be 
facilitated,  and  it  may  be  discovered  that  a  freety  movable 
tumour  exists,  jDcrfectly  suitable  for  operation.  The  anasarca 
in  such  cases  is  due  to  pressure  on  large  veins.  Tapping  under 
these  conditions  is  particularly  indicated  when  there  is  little 
cachexia.  Still,  many  specialists  would  object,  and  say  that 
an  exploratory  operation  is  safer  than  tapping  in  such  a  case, 
as  the  former  will  show  with  certainty  whether  the  tumour  be 


TAPPING    OVARTAX    CYSTS. 


179 


simple,  or  malignant  and  removable,  or  malignant  and  irre- 
movable. 

•  For  tapping  an  ovarian  cyst,  a  tapping  trocar  (Fig.  37)  is 
employed.  The  patient  must  lie  on  her  side,  near  the  edge  of 
the  bed,  the  bladder  having  been  emptied ;  then  an  incision  is 
made  through  the  middle  line,  over  the  most  prominent  part 
of  the  cyst  below  the  umbilicus.  A  lancet  is  best  suited  for 
the  purpose,  and  only  the  skin  must  be  cut.  Then  the  tapping 
trocar  is  thrust  into  the  cyst ;    as   the  fluid  empties  out,  the 


Fig.  88. 


-An  Ovapjan  Cyst  removed  durintg  -Life,  with  a  portion  of 
THE  Abdominal  Walls. 


The  cyst  has  become  an  abscess  cavity,  discharging  pus  through  a  fistulous 
passage  in  the  integuments,  through  \^'hich  a.  glass  rod  has  been  passed.  It  had 
been  treated  by  incision  and  drainage.     [Museum  JR.  C.  S.,  No.  4,553.) 


dome-shaped  end  of  the  cannula  is  pushed  forwards,  and  fixed 
by  the  mechanism  already  described.  A  pad  of  antiseptic  lint, 
secured  by  strapping,  is  placed  over  the  puncture  when  the  fluid 
has  been  removed  ;  then  a  towel,  fixed  by  a  many-tailed  binder 
(page  129),  is  applied  to  the  abdomen,  the  patient  being  placed 
on  her  back.  She  should  remain  about  two  days  in  that  position. 
The  aspirator  may  be  employed  for  tapping  a  cyst. 

The    Listerians    strongly    recommend    full    "  precautions " 


180 


EXAMINATION    OF    ABDOMINAL    TUMOURS. 


during  tapping.  In  anj  case,  the  surgeon  must  be  sure 
about  bis  trocar,  and  the  lubricant  wbicb  be  applies  to  it. 
"  Tbe  most  rapidly  fatal  septicaemia  bas  been  known  to 
follow  tbe  use  of  a  dirtv  trocar  in  tapping  an  ovarian  cyst  " 
(Tbornton). 

Tapping    Parovarian    Cysts. — Some     specialists,    more 
particularly  tbe  Keitbs,  of  Edinburgb,  recommend  tbe  cm'e  of 


Fig.  89. —A  Multilo^llak  Uvaijax  Cyst  removed  dveixg  Life,  with  a 

PORTION   OF  the  ABDOMINAL   WALLS. 

It  had  been  treated  as  in  the  case  of  the  specimen  represented  in  Fig.  88,  without 
any  effect.     {Mitscum  II.  C.  S.,  No.  4,554.) 


simple  broad  ligament  cysts,  tbe  so-called  "  parovarian  "  cysts, 
by  tapping,  and  claim  constantly  successful  results.  Nevertbe- 
less,  I  bave  seen  sucb  a  cyst  requii'e  removal  after  repeated 
tapping,  and  I  bave  known  cases  wbere  other  cysts,  bearing 
all  the  characters  of  the  same  variety,  as  far  as  can  be  ascer- 
tained by  examination  of  tbe  fluid  contents,  proved  to  be 
papillomatous. 


TAPPING    PAROVARIAN    CYSTS I^X'ISION    AND    DRAINAGE.   181 

The  danger  of  removing  a  "  parovarian  "  cyst  by  abdominal 
section  is  very  slight,  tlie  risk  attending  the  tapping  of  a  semi- 
malignant  papillomatous  cyst  is  considerable. 

Incision  and  Drainage. — This  method  of  "curing"  an 
ovarian  cyst  is  absolutely  futile.  Figs.  88,  89  represent  two  cases 
where  this  treatment  proved  a  failure ;  the  cysts  were  removed 
by  Mr.  Thornton,  to  the  immediate  benefit  of  the  patient.  In 
both  cases  the  drainage  had  been  commenced  over  two  years 
before  operation. 

In  the  first,  the  cyst  became  an  abscess  and  discharged  much 
pus ;  in  the  second,  the  drainage  could  not  be  maintained,  and 
the  tumour  remained  almost  unaffected  till  its  removal. 


182 


CHAPTER  YII. 

THE  OPERATIOX  OF  OVARIOTOMY. 

I. — Pkelimixary  Consideratio>'s. 

When  sliould  Ovariotomy  be  Performed? — Ovario- 
tomy should  be  performed  as  soon  as  the  ovarian  tumour  is 
diagnosed.  The  only  exceptions  to  this  rule,  putting  aside 
instances  where  the  patient  is  subject  to  some  other  disease 
jjrejudicial  to  the  recovery  of  the  patient  after  operation,  are 
cases  where  the  cyst  is  exceedingly  small  and  gives  no  pain. 
The  most  experienced  specialists  cannot  always  diagnose 
incipient  cystic  disease ;  an  enlarged  ovary  easily  detected  in 
Douglas's  pouch  on  bimanual  palpation  does  not  demand 
immediate  operation.  When  once  the  tumour  has  risen  above 
the  pelvis,  e^'erything  is  to  be  gained  and  nothing  lost  by 
operating  at  once.  The  larger  the  tumoiu"  grows,  the  greater 
will  be  the  risk  of  rupture,  inflammation,  suppm-ation,  adhesions, 
and  impaired  health.  In  two  of  my  own  cases  the  operation 
was  rendered  very  troublesome  and  dangerous  because  the 
patients  had  been  "advised  to  wait." 

Authorities  are  divided  as  to  the  particular  day  to  be  fixed, 
in  relation,  I  need  hardly  say,  to  the  question  of  menstruation. 
I  have  found  it  most  satisfactory  to  operate  a  few  days  after 
the  disai:)pearance  of  the  "  show."  Some  operators  fix  a  day 
shortly  before  the  period  is  expected.  The  question  is  of  far 
less  serious  import  than  was  formerly  supposed. 

Age  of  the  Patient. — Infancy  and  healthy  old  age  are 
no  bar  to  ovariotomy.  Dr.  Kiister,  of  BerUn,  successfully 
operated  on  a  child  aged  one  year  and  eight  months.  Dr.  J. 
F.  Hooks,  of  Texas,  removed  an  ovarian  tumom-  from  a  child 
thirty  months  old  in  July,  1886.*  The  patient  died  in  twenty- 
*  American  Journal  of  Obstetrics,  vol.  xix.,  p.  1,022. 


OVAKIOTOMY AGE  OF  THE  PATIENT.  183 

four  hours,  but  the  tumour  had  been  tapped  and  there  were 
numerous  parietal  and  omental  adhesions.  Spencer  Wells, 
Thornton,  Barker,  and  Chenowetts  have  all  successfully  operated 
on  children  eight  or  nine  years  old.  In  infancy  the  relations 
of  the  structures  forming  the  pedicle  are  not  likely  to  be 
obscure.  The  ovarian  ligament,  a  most  important  landmark, 
is  hypertrophiecl  and  prominent  (Fig.  90).  These  ovarian 
tumours  in  infants  and  children  are  nearly  always  dermoid. 


Fig.  90. — Ovarian  Disease  ix  a  Still-borx  Child. 

The  left  ovary  forms  a  cyst,  which  is  collapsed.  The  ovarian  ligament,  much 
hypertrophied,  indicates  the  true  seat  of  the  cyst.  (Musemn  B.  C.  S.,  ISTo. 
4,485.) 

Young  girls  are  good  subjects  for  ovariotomy,  provided, 
of  course,  that  the  disease  be  not  greatly  complicated,  and  in 
bad  cases  they  appear  to  stand  shock  very  well.  They  must 
be  carefully  watched  during  convalescence  as  they  are  apt 
to  move  about  too  soon,  to  eat  on  the  sly  any  unwholesome 
luxury  which  their  friends  may  choose  to  bring  them,  and  to 
disobey  the  nurse's  orders  in  many  other  respects. 

In  old  age  the  operation  is  quite  justifiable  when  neither 
organic  disease  is  present,  nor  great  decrepitude  manifest. 
Amongst  my  own  patients  one  of  the  most  rapid  recoveries  was 
made  by  a  widow  aged  sixty-three.  I  assisted  Dr.  Bantock 
several  years  ago  in  the  removal  of  dermoid  cysts  of  both 
ovaries  from  a  woman  also  sixty-three  years  old.  There  were 
strong  pelvic  adhesions,  and  the  operation  was  prolonged  and 
troublesome.  Jan^Tin  and  Wilcke  both  operated  successfidly 
on  a  patient  aged  seventy- seven,  Atlee  on  a  patient  aged 
seventy- eight,  Schroder  on  a  patient  aged  seventy-nine,  and 
on  another  aged  eighty.    Dr.  Miner  performed  ovariotomy  on  a 


184  OVARIOTOMY  :    PRELIMINAKY    CONSIDERATIONS. 

patient  eiglitj-two  years  old,  but  slie  died  on  the  fourteentli 
day.* 

Elderly  patients  are  apt  to  take  broncliitis,  from  the  exposure 
during  operation  and  various  influences  afterwards.  The 
possibility  of  hypostatic  congestion  of  the  lungs  must  not  be 
overlooked. 

Ovariotomy  in  Pregnancy. — Not  many  years  ago  it 
was  considered  hardly  justifiable  to  perform  ovariotomy  during 
pregnancy,  and  when  the  tumom-  was  large  and  growing 
rapidly  the  induction  of  premature  labour  was  recommended 
in  preference  to  the  operation.  Experience,  however,  has 
shown  that  ovariotomy  is  not  attended  with  great  clanger 
when  performed  on  a  pregnant  subject.  It  by  no  means 
necessarily  causes  abortion  ;  indeed,  this  accident,  according  to 
Olshausen,  has  occurred  in  under  twenty  per  cent,  of  all 
recorded  cases,  some  of  which  were  operated  upon  many  years 
ago,  before  ovariotomy  had  reached  its  present  stage  of  perfec- 
tion. Olshausen,  quoting  from  the  statistical  results  of  some 
of  the  operators  who  have  had  the  widest  experience  in  ovario- 
tomy up  to  the  end  of  1885,  states  that  Schroder  has  performed 
ovariotomy  chu-ing  pregnancy  in  12  cases,  Sir  Spencer  Wells 
in  10,  Olshausen  in  8,  and  Tait  in  6.  In  only  one  of  these  36 
cases  did  the  patient  die. 

The  same  authority  shows  that  out  of  21  cases  which  were 
operated  upon  later  than  the  fourth  month  of  pregnancy  only 
2  died,  and  Pippingskold  operated  at  the  beginning  of  labour, 
the  child  was  born  seven  hours  after  the  end  of  the  operation, 
and  the  patient  recovered.  Still  it  is  best  to  operate,  if  possible, 
before  the  fourth  month,  as  the  structm-es  forming  the  pedicle 
become  very  turgid  with  blood  at  a  later  period  of  pregnancy, 
and  this  will  prove  serious  should  there  be  adliesions.  Double 
ovariotomy  has  been  successfully  performed  during  pregnancy, 
as  in  a  case  under  Mr.  Thornton's  care  where  the  tumom^s  were 
dermoid. 


Before  describing  the  operation  in  full,  I  shall  dwell  on  some 

*  See  also  Sir  Spencer  "Wells'  statistics,  Diagnosis  and  Surgical  Treatment  of 
Abdominal  Tumours,  1885,  p.  71. 


ABDOMIXAL    INCISIOX LIGATURE    OF    PEDICLE.  185 

of  its  essential  features,  more  especially  the  abdominal  incision 
and  ligatm'e  of  the  pedicle. 

The  Abdominal  Incision. — A  large  multilocular  cyst 
can,  after  its  septa  have  been  properly  broken  down,  be 
extracted  without  much  difficulty  through  an  incision  but  little 
over  two  inches  in  length.  At  the  same  time,  when  the  incision 
is  short  there  will  be  more  trouble  should  the  cyst  burst  during 
extraction,  nor  will  it  be  easy  to  secm-e  bleeding  points  on  the 
parietal  peritoneum  after  the  breaking-down  of  adhesions. 
When  the  abdominal  walls  are  loaded  with  fat,  the  application 
of  sutures  to  the  edges  of  a  very  short  incision  may  prove 
difficult.  The  operator  need  never  scruple  to  prolong  the 
incision  upwards  in  the  course  of  the  operation  whenever  he 
wishes  to  get  well  within  reach  of  adhesions  high  up  in  the 
abdomen,  or  to  make  room  for  the  extraction  of  a  solid  tumour. 
The  umbilicus  may  safely  be  cut  through,  and  it  is  advisable  to 
remove  the  tissues  which  compose  it,  so  as  to  facilitate  union  of 
the  wound.  As  a  rule,  the  abdominal  incision  should  be  made 
about  three  inches  long.  The  lower  end  should  be  brought  to 
about  two  inches  above  the  pubes,  else  the  securing  of  the 
pedicle  and  the  cleaning  of  the  pelvic  cavity  may  become  difficiilt 
to  effect  properly.  The  extraction  of  the  cyst,  the  contact 
with  the  shanks  of  pressure-forceps,  and  the  prolonged  manipu- 
lations involved  in  ovariotomy,  do  not  seem  to  cause  serious 
bruising  of  the  edges  of  the  abdominal  wound.  Delayed  union, 
of  which  I  have  only  seen  two  marked  cases,  is  due  to  other 
agencies,  such  as  cachexia.  The  best  material  for  sutm'e  is  silk- 
worm-gut or  No.  2  Chinese  silk ;  I  usually  employ  the  former. 

Ligature  of  the  Pedicle. — The  clamp,  once  a  highly 
serviceable  instrument,  is  now  discarded,  and  I  do  not  advise 
the  beginner  to  rely  on  the  cautery.  Ligature  by  transfixion 
is  the  easiest  and  safest  manner  of  secui'ing  the  pedicle.  The 
history  and  principles  of  this  practice  are  fvdly  recorded  in  the 
works  of  Spencer  Wells,  of  several  American  and  Continental 
authors,  and  in  my  own  former  writings. 

After  ligature  and  removal  of  the  tumour,  the  pedicle,  or  more 
correctly  speaking,  the  distal  part  of  the  stiunp  of  the  pedicle, 
is  kept  from  sloughing  by  the  uniform  heat  of  the  interior  of 
the  body  and  by  the  bulging  of  the  tissues  over  each  side  of  the 


186 


OVARIOTOMY  :    PRELIMINARY   CONSIDERATIONS. 


ligatui'e-grooTe.  This  brings  the  distal  portion  at  once  into  close 
contact  with  the  proximal  part,  plastic  lymph  is  rapidly  thrown 
out,  and  soon  becomes  vascular,  so  that  the  pedicle  receives  blood. 
The  changes  above  described  are  well  sho^\Ti  in  Fig.  91.  It 
represents  a  portion  of  the  uterus  and  the  stump  of  an  ovarian 
pedicle  from  a  patient  who  died  of  tetanus  on  the  eighth  day 
after  operation.  The  silk  ligatures  are  completely  concealed. 
A  glass  rod  is  passed  between  them  and  the  deposit  of  lymph 
which  connects  the  bulging  tissues  on  the  distal  and  proximal 
side,  as  just  explained.  Within  a  year  the  pedicle  is  reduced 
to  a  small  fleshy  knob. 


Fig.  91. — Stump  of  ax  Ovakiax  Peuicxe  Oxe  Week  after  Operatiox. 
{IIuseumE.  C.  S.,  No.  4,559.) 

It  is  always  advisable  that  solid  malignant  or  glandular 
material  should  be  carefully  scraped  out  of  the  cut  surface  of  a 
ligatured  pedicle ;  otherwise  the  solid  matter  may  become  the 
starting-point  for  a  recurrence  of  the  disease,  or  more  probably 
it  may  slough  or  undergo  septic  changes.  The  latter  complica- 
tion I  have  detected  at  a  necropsy. 

The  passage  of  a  ligature  through  a  vein  is  an  accident 
always  to  be  avoided,  as  it  may  cause  dangerous  complications. 
The  sm-geon  must  see  that  the  point  of  the  pedicle- needle 
pushes  forward  and  pierces  a  part  of  the  broad  ligament  free 
from  visible  blood-vessels. 

The  splitting  of  the  pedicle  dui'ing  the  process  of  ligatm-e  is 
a  yet  more  serious  accident.     It  is  especially  liable  to  occm-  if 


LIGATURE    OF    PEDICLE — THE    PATIEXt's    APARTMENT.       187 

the  threads  be  not  interlocked,  in  the  manner  presently  to  be 
described.  In  Fig.  92  the  mechanism  of  splitting  is  explained. 
The  hole  in  the  pedicle  over  a  represents  the  point  of  trans- 
fixion. The  unlocked  threads,  pulling  in  the  direction  of  the 
arrows,  tear  the  tissues  asunder  around  that  point.  When  they 
are  interlocked,  they  cannot  tear  the  pedicle  at  a,  and  all  their 
constricting  force  is  spent  on  the  borders  of  the  pedicle  at 
h  and  c. 


Fig.  92. — Diagram  illusteatixg  the  Danger  of  Ligature  of  the  Pedicle 
AFTER  Transfixion,  without  crossing  the  threads. 

After  the  pedicle  has  been  secured  and  some  time  expended 
in  carrying  out  other  details  of  the  operation,  the  surgeon  may 
be  surprised  to  find,  on  taking  a  last  look  at  the  stimip,  that  a 
large  globular  distension  has  formed  on  the  proximal  side  of  the 
ligature.  This  is  a  varix  or,  as  some  would  say,  a  hsematocele 
of  the  pedicle.  It  is  a  frequent  occurrence  of  little  importance, 
and  must  be  left  alone.  A  hsematocele  is  apt  to  form  dming  the 
first  menstrual  period  after  operation. 

The  Patient's  Apartment. — The  selection  of  a  suitable 
room  for  ovariotomy  is  not  an  easy  matter  in  hospital  manage- 
ment. In  private  practice  it  is  often  a  source  of  great  anxiety 
to  the  sm-geon.  The  apartment,  I  may  say,  speaking  in 
general  terms,  should  be  large  enough  for  two  people  to  live 
and  sleep  in  for  several  weeks,  according  to  current  authorities 
in  hj^giene.  The  probability  that  the  operator  may  have  to  sit 
up  and  watch  the  patient  for  a  night,  or  longer,  must  never 
be  overlooked.  In  this  case  arrangements  should  be  made 
for  accommodating  him  with  an  apartment  close,  if  possible,  to 
the  sick  chamber.  This  is  in  accordance  with  that  attention  to 
matters  of  detail  which  Sir  Spencer  Wells  has  shown  to  be  of 
such  importance  in  undertaking  ovariotomy.  If  the  surgeon 
live  near  the  case,  he  must  be  sent  for  should  alarming 
symptoms  arise  in  the  night.  In  this  way  much  time  may  be 
lost,  and  the  surgeon  may  possibly  be  in  a  less  suitable  condition 


188  OVARIOTOMY  :    PRELIMIXARY    CONSIDERATIONS. 

to  encounter  a  serious  complication  than  if  lie  be  in  a  room 
close  to  the  patient.  Indeed,  it  is  not  at  all  rare  for  the  case  to 
be  of  such  a  nature  as  to  make  the  proximity  of  the  surgeon 
highly  advisable  after  the  operation,  whilst  at  the  same  time  it 
wordd  not  be  beneficial  for  him  to  stay  constantly  in  the  room. 
These  remarks  apply,  with  even  greater  force,  to  a  skilled 
assistant.  This  supplementary  apartment  is  verj"  useful  for 
cleaning  the  instruments  after  operation. 

The  jDatient's  apartment  must  be  furnished  with  two  iron 
bedsteads,  one  being  for  the  nurse.  An  oil  cloth,  but  not  a 
woollen  carpet,  is  advisable.  A  table  is  necessary,  for  the 
nurse's  meals  and  for  the  use  of  the  surgeon  when  taking 
notes.  A  cupboard  is  of  considerable  service,  if  well  provided 
with  shelves,  as  it  can  hold  drugs  and  other  necessaries,  and 
thus  save  the  nurse  from  the  needless  trouble  of  having  to 
leave  the  patient  to  seek  for  them  in  other  rooms.  The  siu-geon 
must  never  fail  to  search  the  cupboard  himself  not  only  before 
the  admission  of  the  patient,  but  frequently  during  her  stay  in 
the  room.  Some  nurses,  such  as  I  have  myself  employed, 
appear  perfectly  capable  of  watching  and  caring  for  the  patient, 
yet  imperfectly  conversant  with  the  proper  way  of  storing 
things  in  cupboards,  so  that  just  what  is  needed  may  be  found 
dii'ectly  it  is  wanted  and  taken  out  mthout  any  rumbling  or 
clattering.  A  nurse  may,  unfortunately,  prove  inferior  to 
expectations,  and  old  experienced  hands  tend  to  grow  careless 
and  untrustworthy  ;  assistant  nurses,  also,  may  make  use  of  the 
cupboard  du-ectly  after  the  operation,  unknown  to  their  superior. 
Hence  the  cupboard  may  become  a  receptacle  for  candle-ends 
and  edifying  little  books  heaped  artlessly  over  or  under  sounds 
and  pots  of  vaseline.  Urinometers,  and  other  perishable  yet 
more  or  less  costly  instruments  and  appliances,  may  be  put  on 
the  shelves  in  positions  almost  inviting  destruction,  so  that  just 
when  they  are  wanted  they  may  be  found  broken  or  other-wise 
damaged.  By  a  far  more  serious  oversight,  pans  containing 
tumom-s,  the  contents  of  cysts,  and  vessels  filled  with  cystic 
fluid  or  stale  urine,  are  sometimes  stowed  away  in  a  cupboard 
and  forgotten.  The  operator  may  have  much  to  occupy  his 
mind  after  he  has  seen  his  patient  safely  put  to  bed,  and  if  he 
orders  the  tumoiu-  to  be  preserved,  he  may  neglect  to  forbid  it 


patient's   apartment OPERATING    TABLE.  189 

from  being  kept  in  the  patient's  room.  In  hospital  practice, 
where  an  order  of  this  kind  may  be  systematically  carried  out, 
the  surgeon  must  also  make  sure  that  a  succession  of  cysts  are 
not  accumulating  and  decomposing  in  another  room. 

It  is  self-evident  that  drainage  and  ventilation  must  be  duly 
considered.  In  ordinary  houses  we  know  how  defective  the 
hygienic  conditions  may  be.  Nor  can  the  sui'geon  always  get 
a  plan  of  the  (hi-ains  and  examine  every  pipe  and  see  how  it  is 
ventilated.  He  certainly  ought  to  inspect  the  water-closet 
nearest  the  apartment  and  see  to  sinks  in  upper  stories,  the 
waste-pipes  of  which  may  communicate  with  soil-pipes.  This 
evil  is,  of  course,  very  possible  in  hospitals  and  other  pubhc 
institutions  where  many  sinks  exist,  and  when  the  odour  from 
the  sink  does  not  reach  the  surgeon's  nose  his  suspicions  may 
be  aroused  by  the  sight  of  sickly  warcl-maids  v/ith  sore  throats 
or  pale  faces.  It  is  clearly  impossible  for  me  to  enter  into 
scientific  details  of  hygiene  in  these  pages,  even  were  I  an 
authority  on  that  science.  A  study  of  Mr.  Pridgin  Teale's 
excellent  little  illustrated  work*  will  2)rove  of  great  service  to 
the  surgeon.  A  little  knowledge  may  be  a  dangerous  thing, 
but  inquisitiveness  about  bad  smells  and  inquiries  as  to  where 
slops  are  thrown  cIo'v^ti  will  make  nurses  wonderfully  circum- 
spect. 

As  Sir  Spencer  Wells  has  recommended,  a  horse-hair  mattress 
and  an  open  iron  spring  bedstead  are  advisable  for  the  patient, 
and  the  bed  must  not  be  too  wide,  else  the  patient  cannot  be 
reached  equally  well  from  either  side,  nor  lifted  with  facility. 
Three  feet  and  a  half  is  the  most  convenient  width.  The 
castors  must  act  well,  as  it  may  be  convenient  to  shift  the  bed 
after  a  time,  especially  when  the  patient  is  convalescent.  At 
first,  the  bed  should  never  be  shifted,  and  it  is  not  a  good  plan 
to  wheel  it  alongside  the  operating  table  for  the  transference  of 
the  patient  at  the  conclusion  of  the  operation,  as  the  castors 
may  roll  over  clots  and  cystic  fluid  inadvertently  spilt  on  the 
floor  and  thus  become  fouled.  At  the  Samaritan  Hospital  it 
has  always  been  the  practice  to  carry  the  patient  gently,  in  a 
perfectly  horizontal  position,  from  the  table  to  the  bed. 

The  Operating  Table. — The  table,  or  rather  tables,  may 

*  Dangers  to  Hecdth  :  a  Pictorial  Guide  to  Domestic  Sanitary  Defects, 


190  OVAKIOTOMY  :    PRELIMINARY    CONSIDERATIONS. 

be  of  the  simplest  construction  possible,  but  the  surgeon  must 
make  sure  in  due  time  before  the  operation  that  such  tables  are 
at  hand.  One,  on  which  the  patient's  body  will  rest,  is  placed 
lengthways,  and  the  other  across  the  first,  so  that  the  two  form 
a  T :  the  second  table  will  support  the  patient's  head.  The 
position  of  the  tables  is  indicated  further  on,  in  a  diagram. 
The  tables  should  be  about  three  feet  in  height  and  of  plain 
deal,  not  too  broad  and  without  folding  leaves.  A  horse-hair 
mattress  must  be  laid  on  the  table  intended  for  the  patient's 
body,  passing  on  to  the  other  table,  which  must  be  furnished  with 
pillows  and,  if  possible,  with  a  back-rest  for  the  support  of  the 
shoulders.*  The  mattress  is  covered  with  a  mackintosh  sheet, 
over  which  is  laid  an  ordinary  bed-sheeting.  An  india-rubber 
hot- water  bottle  is  placed  under  the  sheeting  ;  it  should  be  lialf 
filled  with  hot  water,  so  that  the  patient  can  lie  comfortably 
upon  it. 

The  Ovariotomy  Nurse. — Every  woman  who  strives  to 
earn  her  living  as  an  ovariotomy  nm^se  must,  of  course,  begin 
from  the  beginning,  nor  can  she  be  experienced  before  gaining 
experience.  To  relatively  inexperienced  nurses,  unfortunately, 
an  operator  must  sometimes  entrust  a  patient.  The  true  and 
only  good  school  for  her  purpose  is  a  hospital  where  ovariotomy 
and  allied  operations  are  very  frequently  performed.  There 
she  may  watch  her  more  experienced  colleagues,  assist  them  in 
various  duties,  and  relieve  guard  when  a  patient  is  convalescent 
and  not  in  need  of  close  attention.  Then,  in  due  time,  she  will 
be  entrusted  with  the  charge  of  cases  from  the  first.  After  a 
little  experience,  she  will,  if  possessed  with  sufficient  physical 
and  moral  strength,  become  an  ideal  ovariotomy  nurse.  "When 
such  an  education  is  impossible,  the  surgeon  will  have  to  assist 
in  training  his  niu-se  up  to  the  ideal,  a  task  more  difficult  than 
the  operation  of  ovariotomj^  and  far  more  tedious. 

The  ovariotomy  nurse  must  be  not  onh'  at  hand,  but  also 
handy,  when  the  surgeon  examines  and  takes  notes  of  the  case 
before  operation.  She  should  know  how  to  assist  the  patient 
to  lie  in  the  proper  positions  for  examination.  It  is  very 
advisable,  if  her  services  are  to  be  retained,  to  teach  her  to  take 

*  Tlie  hack-rest  is  valuable,  as  it  enables  the  chloroformist  to  raise  or  lower 
the  patient's  head  and  shoulders  rapidly,  ■whenever  advisable. 


THE    OVAKTOTOMY    NURSE.  191 

the  abdominal  measurements.  At  the  Samaritan  Hospital  some 
of  the  nurses  do  this  office  with  great  accuracy,  hut  of  course 
they  must  he  taught,  and  the  sm-geon  should  always  he  present, 
if  possible,  when  the  measuring  tape  is  being  used.  The  nurse 
must  see  that  the  patient,  if  unclean,  is  well  washed  without 
risk  of  chill,  about  twelve  hom\s  before  operation.  She  must 
scrupulously  attend  to  the  surgeon's  dii-ectioas  as  to  the 
management  of  the  bowels,  and  care  must  be  taken  to  make 
sure  that  an  enema  which  has  been  ordered  has  really  been 
given.  Above  all,  the  surgeon  must  impress  upon  her  the 
necessity  of  drawing  off  the  patient's  urine  immediately  before 
operation,  and  must  ascertain  that  she  never  omits  the  precau- 
tion. It  is  exceedingly  unaclvisable  for  the  surgeon  or  his 
assistant  to  have  to  pass  the  catheter  during  operation,  and 
therefore  they  must  rely  upon  the  nurse  in  this  matter. 

The  nurse  must  introduce  the  catheter  every  six  hours,  at 
least,  after  operation,  without  uncovering  the  patient,  thrust- 
ing the  instrument  firmly  against  the  fundus,  or  letting 
urine  escape  on  to  the  becl-clothes.  She  must  sometimes 
empty  the  bladder  more  frequently.  She  must  keep  the 
urine  in  a  graduated  glass  vessel,  till  seen  by  the  sm-geon ; 
then  she  should  ask  him  if  it  is  to  be  kept  or  thrown 
away,  and  she  must  have  the  testing  apparatus  ready.  She 
must  clean  the  catheter  every  time  after  use,  so  as  to  free 
its  eye  from  vesical  mucus,  and  must  keep  it  immersed  in  a 
1  in  40  solution  of  carbolic  acid,  or  any  other  antiseptic 
preparation,  as  the  surgeon  may  direct.  She  must  thoroughly 
understand  how  to  introduce  nutrient  enemata,  taking  care 
that  the  beef-tea  is  never  too  hot,  and  never  neglecting  to  pass 
the  rectal  tube  first.  Here  it  should  be  noted  that  the 
surgeon  must  be  able  to  demonstrate  whatever  he  may  have 
to  direct,  for  sometimes  he  must  teach  his  nurse,  and  then 
it  is  necessary  for  him  to  know  what  he  has  to  teach.  The 
use  of  the  rectal  tube  requires  a  little  delicacy  of  manipula- 
tion. As  remarked  elsewhere,  the  vaginal  tube  of  a  Higgin- 
son's  syringe  will  answer  very  well  for  the  purpose.  Care 
must  be  taken  to  make  sure  that  the  nurse  places  a  small 
pan  or  soap-dish  under  the  tube  to  catch  any  refuse  that 
may  escape.      In   one   of   my  cases,   the   nurse,    willing   and 


192  OVARIOTOMY  :    PKELIMIXARY    CONSIDERATIONS. 

intelligent,  but  inexperienced,  skewed  me  a  fa3tid  rag  freely 
stained  vnth.  beef-tea  and  rectal  mucus,  and  she  had  placed 
it  under  the  tube  several  times  in  twenty-four  hours,  as 
she  "  did  not  want  to  stain  the  bed-clothes."  So  far  she  was 
right,  but  it  was  fortunate  that  I  ascertained  that  an  improper 
kind  of  receptacle  was  being  used. 

The  ovariotomy  nurse  must  exercise  great  judgment  in 
feeding  the  patient,  according  to  directions,  and  must  care- 
fullv  observe  the  effects  of  diet  and  of  drugs.  She  must  take 
the  temperature  \\-ith  perfect  regularity ;  about  once  in  f om-  hours 
is  sufficient.  It  is  advisable  to  train  her  to  take  the  pulse, 
only  the  surgeon  had  best  never  rely  upon  a  nurse  for  this 
office,  which  is  seldom  properly  done,  except  by  those  who 
have  had  a  professional  medical  education.  Still,  there  are 
circumstances  under  which  it  ^ill  aid  the  sm^geon,  if  the  nurse 
takes  the  pulse  every  two  or  three  hours. 

It  is  essential  that  she  should  make  notes  of  everything 
that  has  been  done,  and  of  everji:hing  concerning  the  patient's 
condition.  For  this  pm-pose,  it  ^ill  be  of  great  advantage 
to  the  siu'geon  if  he  leave  her  his  special  note-book  of  the 
case,  in  which  she  can  enter  her  clinical  record.  This  will 
save  him  much  unnecessary  trouble,  in  sitting  long  in  the 
patient's  room  coppng  pencil  notes  into  his  book.  Some 
exemplary  and  enthusiastic  nm-ses  like  to  keep  note-books 
of  theii'  own.  Then,  their-  good  tendencies  should  be  en- 
couraged, and  they  may  be  suffered  to  enter  the  records  in 
their  owti  books.  A  nm-se  of  this  class  will  seldom  object 
to  entering  notes  in  the  sm-geon's  book  as  well,  and,  indeed, 
often  does  so  as  a  matter  of  course  without  being  ordered. 

The  nurse  must  also  know  how  to  manage  the  ice-cap, 
and  the  apparatus  associated  with  it,  and  she  must  be  able 
to  empty  the  cbainage-tube,  though  this  must  always  be 
done  by  the  sm-geon,  if  possible.  She  must  support  the 
abdominal  parietes  when  the  wound  is  being  examined,  and 
not  leave  go  of  them  till  directed.  When  the  bowels  are 
to  be  opened,  she  must  implicitly  obey  the  surgeon,  who, 
of  course,  has  the  right  of  ordering  an  enema,  a  pill,  or 
a  powder,  as  he  thinks  proper.  A  strange  nurse  may  disobey 
such  orders,  and  do  as  directed  by  some  other  surgeon  in  a 


THE    NURSE TREATMENT    BEFORE    OPERATION.  198 

previous  case.  She  should  always  give  direct  replies,  especially 
in  questions  relating  to  the  bowels,  so  that  the  surgeon  may 
he  sure  that  not  only  have  they  been  opened,  but  that  they 
have  been  opened  by  the  means  which  he  desired. 

There  are  many  other  quahties  and  duties  recjuisite  for 
an  ovariotomy  nurse,  not  of  a  character  which  can  be  de- 
scribed in  general  terms.  The  surgeon  cannot  always  expect 
perfection,  and  certainly  will  not  always  get  it.  He  must  never 
be  sm'prisecl  if  the  nurse  gives  him  more  anxiety  than  the 
patient. 

Treatment  before  Operation. — The  patient  should  be 
kept  quiet  for  three  or  four  days  before  ovariotomy.  For 
two  days  at  least  she  should  be  kept  to  her  room,  and 
subjected,  as  old-fashioned  physicians  used  to  say,  to  a  bland, 
unstimulating  regimen,  including  but  little  butcher's  meat. 
Some  patients  try  to  live  well  in  order  to  keep  up  their  strength, 
and  this  they  do  according  to  current  notions  of  popular 
physiology :  that  is  to  say,  they  prepare  for  the  trials  of  an 
operation  by  eating  chops  and  steaks,  and  drinking  good 
wine  of  that  well-known  but  indefinite  brand  which,  accord- 
ing to  their  husbands,  "  cannot  do  anybody  any  harm." 
This  system  tends  to  cause  gastric  disturbance,  an  excessive 
excretion  of  urates,  and  restlessness,  so  that  confinement  to 
the  bed-chamber  is  not  well  borne.  Hospital  patients  are 
often  found  to  have  been  "  fed  up "  in  this  manner,  but 
women  of  the  humbler  classes  of  Hfe  frequently  eat  very  little 
before  subjecting  themselves  to  an  operation  of  this  kind,  and 
they  do  right.  I  beUeve  that  loss  of  appetite,  due  to  antici- 
pation of  an  operation,  has,  as  a  rule,  a  salutary  effect  upon 
the  patient.  The  physical  condition  of  patients  before  ovari- 
otomy is  as  variable  as  before  many  other  major  operations. 
In  one  instance  in  my  experience,  a  stoical  woman,  who  seemed 
quite  indifferent  whether  the  operation  was  performed  or  not, 
took  little  or  no  food,  because  she  had  "  other  things  to  think 
of."  In  another  case  the  patient  exhibited  abject  cowardice  (a 
rare  vice,  somehow,  in  human  beings  about  to  face  real  danger) 
and  extreme  fear  of  death,  yet  she  ate  freely  till  the  morning 
of  operation,  and  soon  regained  her  appetite  afterwards. 

Sir  Spencer  Wells  has  rightly  turned  attention  to  the  im- 


194  O^^ARIOTOMY  :    PRELIMINARY    CONSIDERATIONS. 

portance  of  examination  of  urine  in  every  patient  preparing  for 
operation.  Urine  loaded  with  urates  demands  the  administra- 
tion of  alkalies,  for,  independently  of  the  renal  mischief  which 
this  condition  implies,  it  increases  the  chance  of  irritability 
of  the  bladder  after  operation.  The  citrate  of  potash  is, 
altogether,  the  best  remedy,  and  may  be  given  in  fifteen 
grain  doses,  dissolved  in  a  tumblerful  of  pure  water  or 
soda-water  three  times  daily.  Ferruginous  tonics  are  useful 
for  the  anaemic,  and  are  indicated  when  there  is  a  faint 
trace  of  albumen  in  the  urine.  Tartarated  iron,  with  alkalies, 
is  the  most  valuable  form  of  tonic  under  these  circumstances. 

The  bowels  must  always  be  attended  to,  and  it  is  reasonable 
to  consult  the  p»atient  as  to  her  usual  purgative.  Compound 
liquorice  powder  is  very  efficacious  in  some  cases,  but  others 
are  either  over-purged  or  not  in  the  least  affected  by  it.  Saline 
pui'gatives  sometimes  cause  flatulence.  As  a  rule,  the  colocjmth* 
and  hyoscyamus  pill  is  the  best  purgative  to  administer  before 
operation.  Ten  grains  should  be  given  two  nights  before 
operation.  The  purgative  should  not  be  given  later,  as 
diarrhoea  may  follow  its  administration,  and  last  for  many 
hom\s. 

It  is  of  great  importance  that  the  lower  part  of  the  ali- 
mentary canal  should  be  cleared  of  scj^'bala  shortly  before 
operation.  About  six  hours  pre^^ous  to  ovariotomy  a  simple 
enema  must  be  administered.  The  last  meal  should  be 
taken  about  fom-  hours  before  the  operation,  and  should  con- 
sist of  a  cup  of  good  beef-tea.  This  may  be  seasoned  with 
sweet  herbs  to  make  it  palatable,  for  agreeable  diet  is  a  great 
remedy  against  depression. 

Clothing  for  Operation. — The  patient  should  wear  her 
night-dress,  a  short  flannel  jacket,  and  a  pair  of  warm  stockings 
during  the  operation,  as  recommended  by  Sir  Spencer  Wells. 
As  she  mounts  the  operating  table  she  should  be  dii'ected  to 
tiu'n  vnih.  her  back  to  the  operator,  who  then  raises  her  night- 
gown and  jacket  high  above  the  loins  and  abdomen.  Then 
she  must  lie  down  ■\Adth  the  clothing  well  folded  back  under  the 
loins,  and  not  rucked  up  ;  whilst  a  blanket  is  wi*apped  round 
the  lower  extremities.  The  sleeves  of  the  flannel  jacket  should 
be  di'aAvn  down  well  over  the  wrists,  so  that  the  handcuffs  may 


CLOTHING    OF    PATIENT THE    OPERATION.  195 

be  fastened  round  them,  and  not  over  the  bare  skin  of  the 
forearms. 

Before  any  operation  where  it  is  certain  that  much  fluid 
will  be  evacuated,  it  is  a  good  plan  to  cover  the  arms  with 
towels,  so  that  the  sleeves  may  not  be  drenched.  It  is  also  best 
not  to  trust  too  much  to  the-  waterproof  sheet,  which  may 
become  detached  above,  and  to  lay  a  towel  over  the  epigastrium 
to  protect  the  dress  in  front. 

Should  the  dress  become  blood-stained,  or  partly  soaked  in 
fluid,  the  soiled  portions  must  be  cut  away  at  the  end  of  the 
operation,  and  it  is  sometimes  necessary  to  change  everything. 
In  this  case,  the  change  must  be  effected  with  as  little  dis- 
turbance of  the  patient's  position  as  possible,  and  the  clean 
night-gown  and  jacket  must  be  well  warmed  before  they  are 
put  on. 

II. — The  Operation  of  Ovariotomy. 

Steps  of  the  Operation. — I  shall  now  enter  into  full 
details  concerning  the  different  steps  of  the  operation  of  ovari- 
otomy. I  will  not  merely  describe  an  ordinary  case.  That 
would  be  setting  a  bad  example,  for  no  sm-geon  can  feel  certain, 
before  he  has  opened  the  abdominal  cavity,  whether  the  opera- 
tion will  be  easy  or  difficult.  I  shall,  therefore,  note  the  prin- 
cipal difficulties  which  may  be  encountered  in  connection  with 
those  stages  of  the  operation  where  they  are  most  likely  to  be  first 
recognized,  or  where  they  must  be  finally  overcome.  A  descrip- 
tion of  the  com-se  of  an  operation,  based  on  such  principles, 
must  of  necessity  be  rather  long,  and  I  cannot  avoid  this  dis- 
advantage, for,  as  I  have  just  hinted,  I  object  to  speak  about 
"  simple  ovariotomy."  To  simplify  the  account,  however,  I 
may  tabulate  the  steps  of  the  operation  thus  : 

1.  Placing  the  patient  in  a  correct  position  on  the  table:, 
application  of  waterproof  sheet. 

2.  Abdominal  incision. 

3.  Inspection  of  surface  of  cyst ;  tapping  of  cyst. 

4.  Extraction  of  cyst  collapsed  after  tapjDing;  management 
of  adhesions. 

5.  Ligatm-e  and  division  of  the  pedicle. 


196  THE    OPERATION    OF    OVARIOTOMY. 

6.  Exploration  of  opposite  ovary. 

7.  Introduction  of  sutm'es  into  abdominal  wound. 

8.  Cleaning  of  tlie  peritoneum. 

9.  Counting  sponges  and  forceps. 

10.  Closing  of  abdominal  wound. 

11.  Application  of  dressings. 

This  classification  is,  of  course,  purely  arbitrary.  Difficulties 
may  arise  at  any  step,  even  at  the  first  should  the  patient  be 
much  deformed  through  spinal  disease. 

Instruments  required  for  Ovariotomy. — The  following 
instruments  and  appHances,  most  of  which  have  been  described 
in  Chapter  III.,  will  be  required.     Lister's  apparatus  is  excluded. 

1.  Wristlets,  and  thigh-belt. 

2.  Waterproof  sheet  for  abdomen. 

3.  Two  trays  for  instrmnents,  and  two  bowls  for  sponges. 

4.  Two  stout  scalpels. 

5.  Twenty  pressure-forceps. 

6.  Stanley's  director  for  dividing  peritoneum. 

7.  Scissors  bent  on  the  flat. 

8.  Adams'  peritoneum  hook  (not  indispensable). 

9.  Ovariotomy-trocar  and  cannula,  with  tubing. 

10.  Nelaton's  volsella,  and  a  plain  volsella. 

11.  Cyst  or  large  pressure-forceps,  straight  and  elbowed. 

12.  xArtery-forceps  (torsion  or  ligatm'e). 

13.  Pedicle-needle  (mounted  on  handle). 

14.  Long  free  pedicle-needle,  with  large  eye. 

15.  Xos.  -i-,  1,  2,  3  and  4  silk  (Chinese  twist). 

16.  Sponge-holder.  (The  ordinary  kind,  made  on  the  crayon- 
holder  principle,  will  answer ;  some  operators  prefer  a  long 
forceps  ■^dth  fenestrated  blades,  like  ovum-forceps.) 

17.  Eight  pairs  of  needles,  bearing  silkworm-gut  or  No.  2 
Chinese  twist  silk  tlu-eaded  to  a  needle  at  each  end.  The  pairs  to 
be  pinned  on  to  a  roll  of  muslin,  folded  and  placed  in  the  tray. 

18.  Needle-holder. 

19.  Twenty  sponges  (two  large  flat,  two  small  flat ;  the 
remainder  ordinary  conical  form). 

20.  Strapping,  gauze  (carbolic  or  absorbent),  woollen  pad. 
These  will  be  fully  described. 

21.  Many-tailed  abdominal  binder. 


INSTRUMENTS THEIR   ARRANGEMENT.  197 

22.  Three  or  foiu'  glass  drainage-tubes  of  different  lengths, 
and  india-rubber  cloth  for  same. 

Also  apparatus  for  administration  of  anaesthetic,  brandy,  and 
anything  else  desired  by  the  chloroformist. 

Amongst  the  extra  instruments  advisable  to  have  at  hand 
are  :  a  tapping  trocar  and  tubing,  a  Paquelin's  thermo-cautery, 
Koeberle's  serre-nceud  with  wire,  and  phers  for  fixing  the 
wire,  and  pedicle-pins  (for  transfixing  a  solid  uterine  growth, 
if  necessary :  see  page  124).  A  hand-mirror  should  not  bo 
forgotten  (see  page  87). 

Two  mackintosh  aprons  should  be  at  hand,  as  the  operator 
and  the  senior  assistant  will  require  them.  Each  apron  should 
have  a  bib,  but  no  arms.  .  It  must  be  long  enough  to  protect  the 
surgeon's  clothes  from  the  collar  to  the  boots,  and  must  be 
carefully  washed  after  every  operation. 

Arrangement  of  the  Instruments. — Before  the  patient 
is  brought  into  the  room,  the  instruments  and  sponges  must  be 
carefully  counted  by  the  operator,  and  he  must  see  them  put 
in  the  trays  and  basins,  and  covered  with  antiseptic  solution, 
or  pure  water,  as  the  case  may  be.  They  must  then  be  covered 
over  with  towels,  as  it  is  barbarous  to  leave  an  array  of  glitter- 
ing metallic  instruments  exposed  in  full  sight  of  the  patient,  as 
she  enters  the  room.  The  thigh-belt  and  wristlets  should  also 
be  concealed.  The  operator  must  not  permit  many  persons 
to  be  present  when  the  patient  is  brought  in.  Should  the 
chloroformist  be  a  stranger,  or  likely  to  require  such  a  reminder, 
the  surgeon  must  request  him  to  cover  the  patient's  face  with 
the  lint  or  mask  before  the  straps  are  applied. 

The  patient  should  now  be  brought  into  the  room.  If  very 
timid,  it  is  good  to  give  her  chloroform  in  the  ward  whence 
she  is  taken — indeed,  I  believe  this  practice  should  be  more 
generally  adopted.  When,  however,  the  patient  walks  to  the 
table,  it  is  certainly  easier  to  place  her  in  a  comfortable  position. 
Her  dress  must  be  raised  high  above  the  loins  and  abdomen 
before  she  lies  down,  and  a  blanket  should  then  be  ^\Tapped 
round  her  lower  extremities,  and  tucked  under  her  feet.  I  have 
spoken  at  page  194  of  special  precautions  with  regard  to  di'ess. 
The  operator  and  chloroformist  must  make  sure  that  the  patient 
lies  comfortably  on  the  table,  in  the  supine  j^osition.     Then  the 


198  THE    OPERATION    OF    OVARIOTOMY. 

latter  functionary  commences  his  special  duties.  There  is  no 
necessity  for  him  to  keep  his  hand  on  the  radial  pulse,  as  this 
cannot  he  done  unless  one  of  the  patient's  arms  be  left  free,  an 
objectionable  arrangement.  Even  when  a  Junker's  inhaler  is 
employed,  the  little  finger  of  the  hand  which  holds  the  inhaler 
can  be  kept  against  the  carotid  artery.  Directly  the  patient's  face 
is  covered  by  the  chloroformist,  the  wristlets  should  be  applied, 
and  the  thighs  strapped  down  just  above  the  knees.  In 
hospital  practice,  it  is  fair  to  admit  the  spectators  at  this  stage, 
for  it  is  but  just  that  they  should  learn  as  much  as  possible 
•without  any  kind  of  detriment  to  the  patient. 


Pig.  93. — OvAiimTOMY  :    The  Waterproof  Sheet  applied  to  the  Abdomex. 

The  line  of  incision  is  indicated  by  a  dotted  line.     [Spencer  Wells.) 

The  abdomen  should  then  be  washed  with  a  sponge  and 
antiseptic  solution,  and  the  pubic  hair  may  be  partly  shaved  off 
if  it  grow  high  above  the  pubes,  as  in  some  cases.  The  water- 
proof-sheet is  then  applied  to  the  abdomen.  I  have  already 
given  dii-ections  for  its  application  at  page  87.  Care  must 
be  taken  that  the  hole  in  the  mackintosh  is  neither  too  large* 
nor  too  small.  Its  adhesive  edges  must  be  neatly  adapted  to  the 
integuments  (Fig.  93).  Particular  caution  is  needed  in  sticking 
it  firmly  and  evenly  to  the  skin  over  the  pubes.  The  hair,  if 
thick  or  long,  prevents  firm  adhesion,  and  a  gap  is  thus  left, 


ASSISTANTS POSITION    DURING    OPERATION.  199 

tkrougli  which  blood  and  fluid  may  freely  escape,  soiling  the 
clothes,  or  settling  on  the  hair  around  the  vulva,  where  it  may 
decompose. 

The  operator  and  his  assistants  now  take  off  their  coats  and 
wash  their  hands  in  soap  and  water,  taking  care  to  clean  their 
nails.  Then  they  must  put  on  mackintosh  aprons.  They  next 
must  dip  their  hands  and  forearms  into  a  solution  of  carbolic 
acid,  1  part  in  20,  if  Listerian  precautions  are  to  be  followed. 
The  spray,  also,  should  be  turned  on.  Some  operators,  however, 
do  not  use  the  spray  until  the  peritoneum  is  laid  open.  The 
operator,  assistants,  and  nurses  now  take  their  places. 

Number  of  Assistants. — Though  I  have  already  entered 
into  details  of  most  of  the  subjects  introduced  in  this  chapter, 
and  desire  that  it  should  be  chiefly  descriptive,  I  think  it 
right  to  observe  that  the  question  of  a  second  assistant  is 
important.  It  may  raise  a  difficulty  at  the  last  moment.  If 
the  surgeon  be  little  experienced  in  ovariotomy,  or  be  called 
upon  to  operate  where  the  chief  assistant  and  nurses  have  no 
such  experience,  a  second  assistant  is  important.  At  the 
Samaritan  Hospital  we  seldom  employ  more  than  one,  but  he 
is  always  experienced,  and  generally  has  performed  ovariotomy 
himself.  A  second  assistant  is  useful  to  report  if  there  be  a 
free  flow  of  fluid  through  the  tube  the  moment  that  the  trocar 
is  plunged  into  the  cyst.  He  can  hold  the  tumoui'  steady 
whilst  the  other  sm'geons  are  attending  to  the  pedicle.  Other- 
wise a  heavy  tumour,  with  a  thin  broad  pedicle,  may  slip  over 
the  side  of  the  abdomen  and  tear  itself  partly  away  fi'om  its 
attachments.  During  the  closing  of  the  abdominal  wound,  his 
services  are  useful  in  holding  its  edges  well  together  whilst  the 
operator  ties  the  sutures,  and  the  senior  assistant  sponges  the 
margins  of  the  wound  immediately  in  front  of  each  suture  as  it 
is  made  fast.  However,  the  second  assistant's  services  are  by  no 
means  indispensable  at  this  stage.  A  third  or  foiuih  assistant 
is  worse  than  useless.  The  surgeon  never  requires  any  interme- 
diate person  to  transfer  the  instruments  from  his  hands  to  the 
trays  and  from  the  trays  to  his  hands.  Instruments,  during 
ovariotomy,  should  pass  through  as  few  hands  as  possible. 

Position  of  the  Operator,  Assistants,  and  Nurses. — 
The  operator,  seeing  that  the  light  is  good,  must  stand  on  the 


200 


THE    OPERATIOX    OF    OVARIOTOMY. 


riglit  side  of  the  patient,  with  the  table  for  the  instruments  well 
wdthin  reach  of  his  right  hand.  The  first  assistant  stands  on 
the  left,  facing  the  operator.  The  junior  assistant,  if  present, 
stands  on  the  right  of  the  patient,  close  to  the  operator's  left 
elbow,  the  chlorof  ormist  standing  at  the  head  of  the  table.  The 
chief  nurse  must  stand  close  to  the  junior  assistant,  holding  a 
basin  for  dirty  sponges  or  pieces  of  structures  cut  awaj  in  the 
course  of  the  operation.  She  should  hold  also  a  small  pan, 
containing  clean  sponges  to  be  handed  to  the  operator,  and 
across  to  the  senior  assistant.  A  junior  nurse  must  be  ready  to 
take  the  dirty  sponges  from  her  senior  colleague  and  to  wash 
and  return  them  as  quickly  as  possible,  with  the  assistance  of  a 
ward-maid.  The  following  sketch  will  explain  the  position  of 
all  who  take  part  in  the  operation. 


Rec^tadc 
'y'ar ^fUitd,,  under 
'  tablc^ 


Windou 

of 
Ward 


Sprav 


^«^*f  Assist  t 


Pctns 

Jk)r 

Sponx/cs 


Fig.  94. — Positiox  of  Tables,  Operator,  Assistants,  etc.,  during 
Ovariotomy.  * 


The  Abdominal  Incision. — The  operator  now  takes  up  a 
scalpel,  and  the  senior  assistant  holds  a  sponge  in  his  right 
hand.  It  being  ascertained  that  the  patient  is  completely  imder 
the  influence  of  the  ansesthetic,  the  operator  makes  an  incision 
through  the  integuments  in  the  middle  line  of  the  abdomen, 
beginning  about  three  inches  below  the  umbilicus,  and  continuing 

*  It  is  advisable  to  place  the  spray-apparatus  in  frout  of  the  -(viiido-w  ;  the 
spray  and  the  light  mil  then  fall  in  the  same  line  on  the  area  of  operation. 
"When  the  light  is  obstructed  the  operator  Avill  know  that  there  is  also  something 
in  the  way  of  the  spray. 


THE    ABDOMINAL    INCISION.  201 

for  a  little  under  three  inches  downwards.  If  the  patient 
winces,  the  senior  assistant  must  cover  the  wound  with  a  sponge 
till  she  is  made  thoroughly  insensible  hy  the  chloroformist. 
A  violent  action  of  the  abdominal  muscles,  very  probable  if  this 
precaution  be  not  taken,  may  cause  the  operator's  scalpel  to  cut 
what  ought  not  to  be  cut,  so  that  the  cyst  may  be  opened  or 
a  solid  tumour  wounded  before  the  different  layers  of  the 
abdominal  wound  have  been  evenly  laid  open. 

When  the  wound  in  the  integuments  is  made,  the  senior 
assistant  should  press  and  not  rub  his  sponge  against  bleeding 
vessels.  The  operator  then  takes  pressure-forceps  out  of  the 
trays  and  secures  the  vessels.  It  is  obvious,  now,  that  the 
trays  should  be  close  at  hand  so  that  he  may  never  have  to 
walk  to  them,  nor  even  to  stretch  out  his  right  hand  further 
than  is  absolutely  necessary.  As  I  have  already  hinted,  this 
arrangement  is  better  than  the  system  of  having  the  instru- 
ments handed  by  an  assistant.  It  economizes  labour  and 
promotes  silence.  No  one  should  be  permitted  to  stand 
between  the  operator  and  the  trays.  The  assistant  must  be 
strictly  forbidden  to  sHp.  a  sponge  into  the  peritoneal  cavity 
at  any  stage  of  the  operation.  He  must,  however,  hold  a 
sponge,  frequently  changed,  in  his  hand,  in  order  to  check 
all  oozing  and  to  keep  the  wound  clean.  For  controlling  the 
bleeding  at  this  stage,  some  operators  prefer  that  the  assistant 
should  place  his  finger  on  a  vessel  the  moment  that  it  is  divided. 
A  large  sponge  is,  however,  far  better,  for  it  will  cover  half 
a  dozen  spouting  vessels  if  necessary.  The  operator  need  not 
do  more  than  secure  the  vessels  with  the  pressure-forceps  at  this 
stage,  but  if  a  great  number  require  attention,  the  instruments 
may  be  economized  by  twisting  a  few  of  the  vessels.  The 
pressure-forceps  should,  however,  be  left  on  the  larger  vessels 
as  long  as  possible.  I  strongly  recommend  the  beginner  to 
study  the  observations  on  the  pressure-forceps  (pages  93-100). 
A  vessel  is  not  likely  to  bleed  if  grasped  by  the  forceps  for  over 
five  minutes ;  should  haemorrhage  occur  under  these  circum- 
stances the  bleeding  vessel  must  be  twisted.  I  would  much 
rather,  judging  from  long  experience,  leave  a  ligatm'e  in  the 
abdominal  cavity  than  in  the  abdominal  wound.  In  actual 
practice    the   pressure-forceps   is   sufficient   for   every   divided 


202  THE    OPERATION    OF    OVARIOTOMY. 

vessel  in  tlie  abdominal  wound.  At  the  Samaritan  Hospital 
it  is  rare  to  see  the  ligature  employed.  The  pressure  of  the 
sutui-es  will  be  sufhcient  to  check  recurrent  haemorrhage. 
When  the  pressure-forceps  is  used,  the  vessel  and  the  sur- 
rounding tissues  should  be  seized  obliquely,  then  the  handles 
of  the  instrument  will  lie  conveniently  on  the  abdominal  wall. 
Should  the  vessel  be  seized  vertically,  the  forceps  will  stick  up 
awkwardly  and  get  knocked  about  or  torn  off. 

The  operator  now  divides  the  structures  composing  the  linea 
alba,  keeping  his  eye  on  the  umbilicus  and  cutting  straight. 
In  many  women  there  is  a  dark  line  of  pigment  running  from 
the  umbilicus  to  the  pubes,  and  a  faint  trace  of  this  line  is 
generally  to  be  found.  In  some  cases  a  very  deep  layer  of 
fat  has  to  be  divided.  The  operator  and  his  assistant  must 
take  care,  later  on,  lest  particles  of  the  fat  be  brushed  off 
by  their  hands  and  pushed  into  the  peritoneal  cavity.  The 
sheath  of  one  of  the  recti  is  almost  certain  to  be  opened.  As 
much  care  as  possible  must  be  taken  not  to  cut  outwards,  lest 
more  of  the  rectus  than  its  edge  be  exposed.  The  posterior 
part  of  the  aponeurosis  is  then  divided.  In  the  coiu'se  of  these 
manipulations,  the  senior  assistant  must  ply  his  sponges  steadily 
but  not  officiously.  "When  a  large  vessel  is  seen  in  the  sub- 
peritoneal fat,  it  may  be  seized  by  two  forceps  and  divided 
between  them,  so  as  to  anticipate  haemorrhage.  The  urachus  is 
sometimes  seen  as  a  stout  white  cord. 

The  confidence  inspired  by  skill  in  the  use  of  the  scalpel  and 
a  fair  knowledge  of  anatomy  must  not  be  overweening,  as  the 
operator's  knife  will  now  pass  close  to  very  delicate  normal 
and  morbid  structures.  In  an  ordinary  case,  the  fascia 
transversalis  and  sub-peritoneal  fat  are  reorganized  and  divided. 
Then  comes  the  peritoneum,  and  the  bladder  must  not  be 
forgotten.  I  have  seldom  seen  that  organ  during  this  stage 
of  the  operation,  but  have  never  neglected  to  take  it  into 
account.*  Should  it  be  detected  or  suspected  the  nurse  must 
be  ordered  to  draw  off  the  urine  at  once,  the  knee-strap  being 
loosened  for  the  purpose ;  but  this  should  never  be  necessary  if 
the  nurse  be  competent.     On  no  account  should  the  operator 

*  I  have  never  seen  the  bladder  wounded  by  the  knife  at  this  or  any  other 
stage,  but  I  have  t\\ice  seen  it  lacerated  dui'ing  the  separation  of  adhesions. 


THE    ABDOMINAL    INCISION.  203 

introduce  the  catheter  himself,  nor  attempt  any  other  mani- 
pulation in  the  region  of  the  vnlva  or  anus.  The  first 
difficulty  which  the  surgeon  is  likely  to  meet  is  due  to 
thickening  of  the  peritoneum,  or  its  close  adhesion  to  the 
cyst- wall.  He  must  then  proceed  with  great  caution,  being 
careful  to  cut  at  an  even  depth  along  the  whole  line.  In  spite 
of  all  care,  the  cyst  may  be  cut  into  before  expected.  The 
surgeon  must  then  let  the  contents  escape  and  see  how  far  the 
adhesions  extend ;  in  fact,  continue  the  operation  in  a  later 
stage  yet  to  be  described.  Cutting  too  soon  into  the  cyst  is 
much  less  serious  than  the  opposite  error  of  taking  the 
peritoneum  for  the  cyst-wall  and  detaching  it  from  the 
parietes.  To  avoid  this  mistake  the  operator  must  keep  his 
eye  on  the  parietes  whenever  he  detaches  an  adhesion. 

There  may  be  a  source  of  confusion  of  another  kind.  If 
much  ascitic  fluid  or  a  very  tense  thin-walled  cyst  lie  behind 
the  peritoneum,  the  appearances  are  sometimes  very  pu2;zling. 
The  peritoneum  may  bulge  forward,  so  as  to  resemble  a  cyst 
containing  blood  or  dark  fluid.  A  vertical  scratch  should  be 
made  in  the  middle  line  ;  then,  when  a  little  fluid  has  leaked 
or  shot  out  in  a  jet,  the  true  nature  of  the  case  may  generally 
be  recognized.  If  the  edges  of  a  wounded  thin-wallecl  cyst  be 
seen  they  had  best  be  seized  at  once,  and  the  cyst  can  readily 
be  drawn  out.  Here  I  may  observe  that  the  peritoneum 
never  looks  like  the  surface  of  a  healthy  cyst,  but  an 
inflamed  or  degenerating  cyst  may  resemble  diseased  peri- 
toneum. 

Ascitic  fluid  may  always  be  allowed  to  flow  out,  the  senior 
assistant  pressing  both  flanks  gently.  When  this  happens, 
especially  if  the  case  be  not  very  clear,  the  operator  must 
look  out  for  evidence  of  free  malignant  or  papillomatous 
growths.     More  will  be  said  on  this  matter  shortly. 

The  ovariotomist  should  never  be  unprepared  nor  startled ; 
that  is  why  I  have  dwelt  upon  difiiculties  first.  As  a  rule,  he 
will  recognize  the  peritoneum  readily.  He  should  raise  a  piece 
of  that  serous  membrane  on  the  point  of  the  scalpel,  and  make 
a  small  hole  in  it.  Adams'  peritoneal  hook  (page  101)  seems 
to  me  an  unnecessary  instrument.  Not  rarely  the  peritoneum 
is  found  to  be  evidently  free  from  adhesion  to  deeper  structures. 


20-4  THE    OPERATION    OF    OVARIOTOMY. 

Then  it  may  be  gently  scratched  through  with  the  point  of 
the  scalpel,  care  being  taken  not  to  damage  the  cyst- wall. 
The  hole  being  made,  a  Stanley's  director,*  or  any  other  stout 
director,  may  be  passed  upwards  along  the  middle  line  ;  the 
peritoneum  is  then  laid  open  mth  a  scalpel  or  scissors,  and  the 
same  manoeuvre  is  repeated  downwards,  so  that  the  serous 
membrane  is  divided  along  the  whole  line  of  the  abdominal 
woimcl.  The  operator  will  now  feel  a  sensation  akin  to  satisfac- 
tion on  seeing  the  shiny  white  surface  of  the  ovarian  cyst. 

Morbid  Conditions  discovered  after  the  Peritoneum 
is  laid  Open. — Yet  before  turning  to  the  management  of  the 
cyst,  I  must  take  into  accoimt  some  more  difficulties  which  may 
present  themselves  at  this  stage,  when  the  peritoneum  is  freely 
laid  open.  The  tumour  may  prove  to  be  uterine,  or  to  be  a  sohd 
ovarian  growth.  What  then  should  be  done  will  be  described 
later  on.  It  may  be  a  ruptured  ovarian  cyst.  If  the  effused 
fluid  be  sweet,  it  may  be  removed  by  sponging  and  pressure 
on  the  abdominal  walls.  If  it  be  colloid  or  otherwise  semi- 
sohd,  it  may  be  removed  by  the  hands.  When  it  is  clearly 
foetid,  the  hands  must  be  scrupulously  kept  out  of  it.  I  do 
not  like  sponging  under  these  circumstances.  The  sjDonges 
will  be  tainted  and  difficult  to  pmify,  and  yet  they  ma}^  be 
wanted  for  an  untainted  part  of  the  peritoneum,  since  foetid 
fluid  may  lie  in  a  circumscribed  area.  Far  better,  when  de- 
composing fluid  has  to  be  removed,  is  Mr.  Lawson  Tait's  plan 
of  pom-ing  pitchers  full  of  water,  at  blood  heat,  into  the  peri- 
toneal cavity.t  This  may  be  done  till  the  water  flows  out  clear 
and  sweet.  Of  course,  weak  carbolized  solutions  may  be  used 
by  those  who  adopt  Listerian  precautions.  As  the  water 
escapes,  the  senior  assistant  should  see  that  the  mackintosh 
has  not  become  detached  from  its  adhesion  to  the  skin  of  the 
pubes,  else  the  patient's  thighs  and  the  linen  beneath  her  will 
be  drenched. 

*  See  reference  to  this  insti-ument  and  to  Adams'  hook  in  Chapter  III. 

t  Mr.  Tait's  name  has  been  rightly  associated  with  this  practice,  as  far  as  its 
use  in  abdominal  section  is  concerned.  The  hfeniostatic  properties  of  hot  water, 
one  of  the  most  important  factors  in  producing  the  excellent  results  which 
follow  the  flushing  out  of  the  peritoneum,  was  first  pointed  out  by  Mr.  Keetley 
in  1879  ("Hot  Water  as  an  Hemostatic  in  Surgevy,"  Practitioner,  vol.  xxii., 
p.  113).     Dr.  Gill  Wylie  believes  that  the  hot  water  counteracts  shock. 


APPEARA]?fCES    OF    CONTENTS    OF    PERITONEUM.  205 

Then,  when  the  peritoneum  is  laid  open,  the  tumour  may 
turn  out  to  be  a  diffuse  malignant  or  papillomatous  mass 
covering  the  parietes  or  the  omentum  and  intestines  or  stand- 
ing high  out  of  the  pelvis.  There  is  sure  to  be  free  fluid 
under  these  circumstances.  The  operator  must  handle  the 
growths  quite  gently,  just  enough  to  recognize  them  by  touch, 
and  the  assistant  must  not  press  the  flanks  to  accelerate  the 
escape  of  the  free  fluid.  If  these  precautions  be  neglected, 
free  haemorrhage  will  take  place,  and  will  prove  very  trouble- 
some, if  not  impossible,  to  check.  When  as  much  fluid  as 
will  run  out  spontaneously  has  escaped,  the  operation  must  be 
at  once  concluded  by  sewing  up  the  abdominal  wound. 

The  management  of  a  multilocular  ovarian  cyst,  properly 
exposed,  must  now  be  described.  When  the  cyst-wall  is  free 
from  inflammatory  changes  it  is  white  and  shiny.  Its  ap- 
pearance is  highly  characteristic.  The  boldest  as  well  as  the 
most  timid  and  inexperienced  operator  must  never  feel  over- 
eonfldent  when  he  has  arrived  in  full  sight  of  a  tumour  bear- 
ing the  aspect  of  a  multilocular  ovarian  cyst,  for  if  it  be 
a  growth  of  that  class  there  may  yet  be  great  difficulties  in 
the  further  stage  of  the  operation.  If,  however,  the  surface 
of  the  tumour  present  a  different  appearance,  caution  will  be 
particularly  necessary,  both  as  regards  diagnosis  and  the  further 
steps  of  the  operation.  First  comes  the  chance  of  error  in  dia- 
gnosis ;  next,  the  high  probability  of  some  complication  should 
the  tumour  be  really  ovarian. 

The  appearance  of  a  pregnant  uterus  is  characteristic,  but 
not  so  as  to  be  readily  described  or  figured.  The  operator 
must  never  leave  pregnancy  entirely  out  of  his  calculations; 
even  at  this  stage  singular  errors  have  arisen  from  neglecting 
this  precaution.*  Uterine  fibroids  are  of  a  pale  brick-red  colour, 

*  "When  assisting  Dr.  Bantock  at  an  operation  for  the  removal  of  a  multilocular 
cyst  from  a  woman  known  to  be  over  seven  months  pregnant,  I  observed  that  the 
uterus  was  of  the  "pale  brick-red  colour"  described  above  as  a  characteristic  of  a 
uterine  fibroid,  and  it  felt  not  unlike  a  somewhat  soft  tumour  of  that  class.  The 
softness  of  the  expanded  cervix,  the  detection  of  the  foetal  head,  with  distinct 
ballottement  close  to  the  brim  of  the  pelvis  in  front  of  the  cervix,  and  a  very 
reliable  history,  were  sufficient  safeguards  against  error  in  this  case.  Had,  how- 
ever, the  patient  fancied  that  she  was  not  i^regnant ;  had  the  cyst,  and  not  the 
uterus,  lain  nearest  to  the  pelvic  brim,  so  that  the  cervix  might  have  been  too 


206  THE    OPERATION    OF    OVARIOTOMY. 

owing  to  the  presence  of  plain  muscular  fibres  and  consider- 
able vascularity.  Sometimes  the  surface  of  a  fibroid  is  very 
pale  indeed,  so  as  closely  to  resemble  that  of  an  ovarian  cyst ; 
and  if  the  fibroid  be  cystic,  there  will  be  some  difficulty  in 
diagnosis  at  this  stage.  A  fibroid  bleeds  violently  even  if  only 
slightly  cut  with  the  scalpel.  In  many  ovarian  or  broad  liga- 
ment tumours  which  have  become  invested  anteriorly  by  a  layer 
of  the  broad  ligament,  the  surface  also  appears  reddish  in  tint. 
The  presence  of  the  tube,  stretched  and  elongated  over  the 
wall  of  the  tumour,  also  indicates  a  tumour  of  this  class,  and 
may  presage  an  easy  operation,  or  else  imply  that  some  deeper 
complication  exists,  for  tumours  which  burrow  into  the  folds  of 
the  broad  ligament  often  have  very  troublesome  pelvic  con- 
nections. The  tube  and  broad  ligament  may  happen  to  lie  on 
the  front  of  an  ordinary  multilocular  cyst ;  in  this  case  the 
exposed  surface  appears  like  a  veil  of  thin  red  membrane, 
covering  deeper  structures  and  very  vascular ;  the  tube, 
generally  below,  can  be  recognized.  On  pushing  this  mem- 
brane aside,  the  characteristic  surface  of  the  cyst-wall 
will  be  exposed.  When  uncertainty  exists  about  the  tumour 
being  of  ovarian  or  uterine  origin,  fm"ther  exploration  will  be 
necessary  even  for  bare  diagnosis.  The  abdominal  wound  will 
have  to  be  enlarged,  and  the  pelvis  carefully  explored,  until 
the  relations  of  the  uterus  can  be  made  out. 

When  secondary  cysts  bulge  freely  from  the  surface,  the 
chances  are  that  the  tumour  is  an  ordinary  multilocular 
cyst.  When  the  cj^st-wall  is  smooth  and  shiny,  but  greenish- 
grey  and  semi-transparent,  the  tumour  probably  contains  a 
great  quantity  of  adenomatous  growth.  Malignant  ovarian 
tumours  are  usually  dull  brown  or  yellow  coloured;  some- 
times they  may  be  recognized  at  once  as  solid  masses  of  sar- 
coma, but  when  they  contain  large  cysts  their  diagnosis  before 
tapping  is  often  uncertain,  the  cyst  which  presents  at  the  wound 
possibly  bearing  no  malignant  characters.  A  cyst  with  a 
whitish  surface,  rather  dull,  and  not  very  smooth,  is  probably 
an    ovarian  cyst  with  a  twisted  pedicle.     A  dull- white  cystic 

liigh  for  digital  exploration  ;  and,  lastly,  had  the  patient  been  under  the  care  of 
a  relatively  inexperienced  operator,  I  believe  that  the  gravid  uterus  might  very 
l)robably  have  been  mistaken,  during  the  operation,  for  a  fibroid  tumour. 


APPEARANCE    OF    CYST TAPPING.  207 

tumour  with  orange  or  oclireous  patches  is  very  possibly 
dermoid. 

So  far  will  the  operator  see  his  way  at  this  stage.  In  most,  if 
not  all  the  above  eases,  excepting  pregnancy,  and  in  some  kinds 
of  uterine  fibroid  and  advanced  malignant  disease,  he  will  have 
to  continue  the  operation.  The  chief  object  of  the  above 
remarks  is  to  remind  the  surgeon  that  he  must  be  the  more 
cautious  in  using  the  trocar  the  less  characteristic  the  surface 
of  the  tumom-  appears.  Plunging  that  instrument  into  a  soft 
uterine  fibroid  would  cause  severe  hsemorrhage,  impossible  to 
check  without  removing  the  t amour  entire.  When  the  sur- 
face of  a  uterine  fibroid  has  been  exposed  and  wounded  by  the 
scalpel,  and  the  surgeon  finds  that  the  tumour  is  not  suitable 
for  removal,  a  needle  threaded  with  No.  1  silk  must  be  passed 
under  the  bleeding  point,  so  that  two  ends  of  the  silk  lie  on 
each  side  of  that  point.  Should  the  bleeding  not  cease  when 
the  ends  of  the  silk  are  drawn  tight,  one  end  must  be  threaded 
on  to  the  needle,  passed  over  the  bleeding  point,  and  then  through 
the  tissues  under  that  point.  On  tying  the  ends,  the  tissues  mil 
then  pucker  and  the  bleeding  vessel  will  be  firmly  held. 

Tapping  the  Cyst. — When,  however,  the  surface  of  the 
tumour  bears  the  characters  seen  in  multilocular,  dermoid,  or 
broad-ligament  cysts,  it  is  best  to  proceed  at  once  to  tapping. 
Adhesions  of  every  kind  are  more  manageable  when  the  cyst 
has  collapsed  than  when  it  is  full.  If  the  operator  should 
attempt  to  break  down  adhesions  at  the  upper  limits  or  sides 
of  the  cyst  before  tapping,  there  may  be  severe  hsemorrhage 
behind  the  tumom*,  difficult  to  reach  until  the  whole  process 
of  emptying  the  tumour  and  drawing  it  more  or  less  out  of 
the  abdominal  wound  has  been  concluded.  Besides,  the  ope- 
rator may  lacerate  a  portion  of  intestine  tightly  stretched 
over  a  tense  cyst  and  firmly  adherent  to  its  walls,  without 
even  recognizing  the  natm^e  of  the  adherent  structure  till  it  is 
too  late.  Such  an  accident  is  far  less  probable  when  the  cyst 
is  collapsed.  Still,  slight  parietal  adhesions  close  around  the 
abdominal  wound  may  be  gently  separated  by  passing  the 
hand  into  the  abdominal  cavity  between  the  cyst- wall  and  the 
peritoneum.  A  piece  of  omentum  evidently  adherent  to  the 
front  of  the  cyst  should  be  separated  and  held  in  the  grasp  of 


208 


THE    OPERATION    OF    OYAKIOTOMY. 


pressure-forceps,  to  be  tied  later  on.  These  two  last  man- 
ceuvres  will  prevent  difficulties  in  fixing  the  spring  hooks  of 
the  cannula,  which  may  arise  if  there  be  close  adhesions  up 
to  the  very  limits  of  the  abdominal  wound. 

The  trocar  (page  102)  is  now  thrust  into  the  cyst  (Fig.  95), 


Fig.  95. — Ovariotomy  :  The  Trocar  plunged  into  the  Cyst. 
[Spencer  Wells.) 

and  the  operator  will  know  if  the  fluid  be  escaping  by  the 
collapse  of  the  cyst-walls  and  the  rush  of  the  fluid  into  the 
receptacle  below.  As  the  cyst  collapses  the  point  of  the  trocar 
is  drawn  up  into  the  cannu.la,  and  the  cyst-walls  around  the 
apertm-e  are  pulled  up  and  caught  in  the  spring  hooks  (Fig.  96). 


Fig.  96. — Ovariotomy:  Extraction  of  the  Cyst  through  the 
Abdominal  Wound,     [Spencer  Wells.) 

In  order  to  bring  the  walls  well  up  to  the  hooks,  the  long- 
handled  volsella  (page  106)  should  be  used.  If  the  cyst  be 
pulled  up  by  the  assistant's  hand  there  will  be  more  risk  of  the 


EXTRACTION    OF    CYST REDUCTION    OF    ITS    BULK.  209 

escape  of  fluid  into  the  peritoneal  cavity.  The  operator 
must  never  think  of  thrusting  the  trocar  deeply  into  the  cyst 
cavity,  with  the  teeth  opened  so  as  to  catch  a  piece  of  cyst-wall 
at  haphazard,  without  the  aid  of  another  hand  or  instrument. 
In  the  simplest  cases,  the  tumour  may  now  come  out  mth  a 
run.  A  second  assistant  may  support  it,  if  it  slides  out  rapidly, 
and  the  senior  should  see  that  no  prolapse  of  intestines  occm-s. 
This  he  can  prevent  by  pressing  a  sponge  gently  on  the  upper 
angle  of  the  wound  whilst  the  cyst  is  coming  out.  Some  opera- 
tors, dreading  the  chance  of  a  sponge  being  slipped  into  the 
abdominal  cavity  by  any  one  but  themselves,  forbid  this  practice. 
They,  however,  direct  the  senior  assistant  to  prevent  prolapse 
by  catching  hold  of  the  integuments  on  each  side  of  the  upper 
part  of  the  wound,  between  the  fingers  and  thumb.  I  object 
to  this,  as  the  assistant's  hands  being  generally  moistened  with 
blood,  with  the  water  from  the  sponges,  or  even  with  glairy 
fluid  escaped  from  the  cyst,  he  is  very  apt  to  let  the  integu- 
ments slip  at  the  most  critical  moment,  when  they  fly  apart,  and 
the  accident  which  it  was  intended  to  prevent  will  probably 
occm\  This  misadventure  I  have  witnessed  more  than  once. 
In  short,  the  assistant  had  better  be  trusted  with  his  sponge. 

Sometimes  a  large  secondary  cyst  is  detected  ;  then  it  may  be 
tapped  by  means  of  the  trocar.  More  than  one  such  cyst  may 
require  this  treatment.  Should  the  fluid  contents  be  foetid  or 
jDurulent,  it  is  very  advisable,  if  possible,  to  complete  the 
emptying  of  the  cyst  entirely  by  means  of  the  trocar.  In  this 
Avay,  not  a  drop  need  escape  except  into  the  receptacle  below 
the  table.  The  collapsed  cyst  must  then  be  hung  well  to 
the  operator's  side  of  the  patient,  so  that  the  fluid  which 
remains  maj'^  not  leak  over  the  patient's  body. 

Reduction  of  the  Bulk  of  the  Tumour  by  Breaking- 
down  Secondary  Cysts. — If,  however,  the  contents  be  clear, 
glairy,  and  evidently  aseptic,  the  operator  may  without  scruple 
break  clown  secondary  cysts  with  his  hand,  after  unfixing  the 
spring  hooks  of  the  trocar  and  letting  it  drop  into  the  batli. 
Too  great  reliance  on  the  trocar  may  involve  wounding  of  the 
posterior  part  of  the  cyst- wall.  In  any  case  when  the  secondary 
cysts  are  small  and  numerous,  or  when  abundant  glandular 
growths  exist,  the  interior  of  the  tumour  must  be  broken  down 

p 


210 


THE    OPERATION    OF    OVARIOTOMY. 


by  means  of  the  operator's  hand,  nntil  the  tumom-  is  reduced 
to  a  bulk  sufficiently  small  to  allow  of  its  removal  through  the 
abdominal  wound. 

This  manipulation  must  be  done  with  caution,  yet  not  too 
slowly,  and  the  beginner  will  find  it  harder  than  he  expected. 
The  cannula  having  been  withdrawn,  the  hole  in  the  cyst  must 
be  widened  by  tearing,  or  cutting  with  scissors.     The  edges  of 


Fici.  97. — 0\'Ai:ioTOJiY,  Bkeakixcj  down  Solid  JIatteu. 

The  operator's  haiul  is  introduced  into  the  cavity  of  the  cyst,  in  order  to  break 
■down  secondary  cysts  and  solid  matter.  The  ent  edges  of  the  cyst  are  kept  apart 
]jy  Xelaton's  volselh^,  hekl  by  an  assistant ;  his  left  hand  is  represented  con- 
siderably to  the  left  of  its  true  position,  so  as  not  to  cover  the  outline  of  the 
operator's  hand.     {After  Savacje.) 

each  side  of  the  rent  are  seized  1)y  means  of  a  Xelaton's  volsella. 
The  senior  assistant  should  then  hold  the  two  forceps,  one  in 
each  hand,  well  apart  so  as  to  make  the  rent  as  wide  as  possible 
(Fig.  97).  Then  the  operator  thrusts  his  right  hand  into  the 
cyst.  The  assistant  must  see  that  lie  holds  the  edges  of  the 
rent  well  above  the  level  of  the  wound,  and  must  take  care  that 
the  cj'st-wall  does  not  get  torn  away  from  one  of  the  forceps. 
If  this  oeciu*  at  a  critical  moment,  he  should  catch  the  cyst- 


MANAGEMENT    OF    SECONDARY    CYSTS ABSENCE    OF    PEDICLE.    211 

wall,  below  the  yielding  point,  between  the  nails  of  his  fingers 
and  thnmb  and  hold  it  well  up.  No  doubt,  the  less  the  operator 
and  assistants  touch  the  interior  of  the  cyst  the  better,  but 
I  am  speaking  of  a  comparatively  exceptional  condition  of 
things.  The  cyst-wall  is  generally  tough  enough  to  bear 
gentle  traction  with  the  forceps.  As  long  as  the  assistant 
keeps  the  cyst  held  up  properly,  there  is  little  fear  of  prolapse 
of  the  viscera. 

The  operator,  with  his  right  hand,  deliberately  breaks  down 
small  cysts  and  solid  matter,  taking  great  care  not  to  burrow 
too  deep  and  endanger  the  back  of  the  cyst.  If  that  be 
wounded,  the  contents  will  run  into  the  pelvis,  and  prolapse  of 
some  of  the  viscera  into  the  cyst-cavity  may  take  place.  After 
a  little  breaking  down  the  tumour  can  generally  be  drawn  out 
with  facility,  provided  there  be  no  adhesions.  If  adhesions 
exist  they  must  be  separated,  for  the  great  danger  of  too  free 
breaking  down  of  the  interior  of  the  tumour  is  copious  haemor- 
rhage, which  cannot  always  be  thoroughly  arrested  till  the 
pedicle  is  reached.  Before  the  adhesions  have  been  attended 
to,  it  may  not  be  possible  to  reach  the  pedicle.  If  free  hsemor- 
rhage  suddenly  occm-  diu-ing  the  process,  the  surgeon  should 
draw  up  one  side  of  the  cyst,  from  without,  as  far  as  he  can,  so 
as  to  reach  the  pedicle,  and  then  secure  it  by  means  of  a  large 
pressm-e- forceps  with  bent  blades  (page  109).  If  the  pedicle 
cannot  be  reached,  the  lowest  portion  of  the  tumour  must  be 
seized  by  the  large  pressure-forceps.  That  instrument  must 
be  used  in  a  similar  manner  should  the  cyst  be  extensively  rent 
or  bluest  during  the  process  which  is  now  being  described. 

Absence  of  Pedicle :  Abnormalities  in  the  Pedicle, 
and  how  to  treat  them. — In  the  more  abnormal  cases,  as 
in  a  perfectly  sessile  tumour,  the  lowest  part,  secm-ed  b}^  large 
pressure-forceps,  will  have  to  be  made  into  a  pedicle.  On  the 
other  hand,  the  tumour  may  prove  to  be  ovarian,  yet  severed 
from  its  pedicle  (Fig.  100).  In  this  case  it  is  generally  adherent 
to  the  great  omentum,  which  may  be  tied  in  one,  two,  or  more 
pieces,  with  No.  1  silk,  and  then  cut  away  ;  the  tumour  may 
then  be  gently  drawn  out.  The  pelvic  viscera  should  be  explored 
with  the  finger  to  make  sure  that  the  tumoiu-  has  not  really  been 
torn  off  in  the  com-se  of  the  operation.    If  the  ovary  be  missing 


212  THE    OPERATION    OF    OVARIOTOMY. 

on  one  side,  the  nature  of  the  case  ^vill  be  self-evident.  Sometimes 
a  detached  tumour  is  universally  adherent,  and  the  absence  of 
the  pedicle  vdll  not  be  discovered  till  after  the  adhesions  have 
been  separated.  There  are  cases  in  which  the  pedicle  can  be 
easily  reached  after  the  collapse  of  the  empty  cyst,  though  the 
latter  be  strongly  adherent  to  the  peritoneum  and  intestines. 
In  such  cases  the  surgeon  may  be  thoroughl}'  justified  in  apply- 
ing the  ligature  to  the  pedicle  and  separating  it  from  the 
tumour.  The  adhesions,  especially  if  high  in  the  abdomen, 
may  then  be  broken  down  with  comparative  ease.  In  this  case  the 
distal  or  tumour  side  of  the  pedicle  must  be  secured  with  large 
pressure-forceps  before  the  pedicle  is  cut  through,  else  the 
tumoui'  may  bleed  whilst  vascular  adhesions  remain  undivided. 

Treatment  of  Adhesions. — After  the  tapping,  adhesions 
ma}-  have  to  be  divided.  Firstly,  there  may  be  none  at  all, 
and  as  this  sometimes  is  the  case  when  their  presence  has  been 
suspected,  the  surgeon  must  never  pull  hard  on  the  cyst-wall 
in  extracting  the  tumour.  Should  he  do  so  when  the  cyst 
happens  to  be  heavy  and  unfettered  by  adhesions,  it  may  shp 
out  of  the  abdominal  wound  too  quickly,  and  be  followed 
perhaps  by  several  coils  of  intestine. 

Adhesions  to  omentum  are  very  common.  The  omentum 
must  be  carefully  tied  with  No.  ^  or  No.  1  silk,  a  pressure-forceps 
should  then  be  placed  on  the  distal  side  of  the  ligature,  and  the 
omentum  must,  lastly,  be  cut  thi'ough  between  the  silk  and  the 
forceps.  The  omentum  may  require  two  or  more  ligatm'es,  to 
be  applied  in  this  manner.  Holes  often  form  in  adherent 
omentum.  The  omentimi  must  be  tied  separately  on  each 
side  of  a  hole  and  then  divided.  This  precaution  is  obvious, 
when  we  remember  that  hernia  of  intestine  and  subsequent 
strangulation  might  be  caused  by  leaving  a  hole  in  the 
omentum.  In  cancerous  tumoiu's  of  the  ovary,  the  omental 
vessels  may  be   so   large  as   to  need  No.  2  silk  for  ligatm-e. 

Soft,  vascular,  parietal  adhesions  must  be  broken  down,  slowly 
and  steadily,  by  gentle  pressm-e  ^^^.th  a  sj)onge.  Before  sepa- 
rating them  the  surgeon  must  wash  his  hands,  if  they  be  stained 
with  cyst  fluid.  "When  a  large  raw  surface  is  left  on  the 
parietal  peritoneum  after  separation  of  an  adhesion,  a  sponge 
should  be  kept  against  it,  and  this  will  generally  check  hsemor- 


TKEATMENT    OF    ADHESIONS.  213 

rhage.  Wlieii  a  small  artery  is  divided,  it  should  be  seized 
with  pressure-forceps,  or  secured  with  No.  1  silk. 

It  is  not  always  easy  to  catch  hold  of  the  artery  with  forceps 
owing  to  the  oblique  position  of  the  vessel  in  relation  to  the 
plane  of  the  peritoneum  where  it  lies.  Its  retractility  under 
the  surface  of  the  peritoneum,  and  the  mechanical  obstacles  to 
placing  that  surface  in  a  comfortable  position  for  the  surgeon 
who  uses  the  forceps,  add  to  the  difficulty  of  securing  the 
vessel.  Hence,  when  a  bleeding  vessel  is  hard  to  secure  for  any 
of  the  reasons  just  stated,  the  best  way  of  settling  the  difficulty 
is  to  pass  the  ligature,  by  means  of  a  needle,  behind  the  vessel 
just  above  its  bleeding  orifice.  In  this  way  the  peritoneum  is 
transfixed  on  both  sides  of  the  vessel.  The  ligature  being  tied, 
the  vessel  will  be  firmly  secured.  In  some  cases  many  freely 
bleeding  points  may  be  detected  on  examining  the  peritoneum. 
The  haemorrhage  must  then  be  checked  by  the  application  of 
Paquelin's  cautery. 

Adhesions  to  intestine  require  very  careful  treatment.  The 
sponge  must  be  gently  pressed  against  the  line  of  adhesion, 
the  pressure  being  directed  towards  the  cyst,  and  not  in  the 
direction  of  the  bowel.  In  this  way  the  adhesion  will  separate, 
and  possibly  a  thin  lamina  from  the  cyst  will  remain  on  the 
intestine.  If  the  pressure  be  directed  too  much  towards  the 
intestine,  the  surgeon  may  soon  expose  its  muscular  coat,  or, 
worse  still,  its  interior.  The  senior  assistant  should  keep  a 
sponge  gently  pressed  on  the  intestine.  This  is  particularly 
necessary  if  it  be  distended,  yet  even  if  flaccid  its  outhne  along 
the  line  of  adhesion  is  more  readily  seen  by  the  operator  when 
it  is  pressed  down  in  this  manner.  When  the  cyst  is  strongly 
adherent,  it  is  best  to  cut  a  piece  away  and  leave  it  on  the 
intestine,  peeling  off  as  many  laminte  as  can  safely  be  managed. 
A  very  thick  piece  of  cyst- wall  may  slough,  as  I  have  proved 
by  post-mortem  evidence ;  and  as  a  cyst- wall  is  nearly  always 
laminated,  this  23eeling  can  generally  be  managed.  As  a  rule, 
however,  intestinal  adhesions  are  not  over  tough.  There  is 
often  free  haemorrhage  requiring  ligature  of  small  arteries. 

If  a  piece  of  intestine  be  torn  the  wound  must  be  sewn  up  by 
a  continuous  silk  suture.  The  needle  must  transfix  the  serous 
coat  on  each  side  of  the  rent  at  every  stitch,  so  that  when  the 


214  THE    OPERATION    OF    OVARIOTOMY. 

suture  is  tied,  the  peritoneal  surfaces  may  be  brought  well 
into  contact.  Wells,  in  one  case,  remoyed  about  three  inches 
of  diseased  and  adherent  intestine,  and  obtained  complete  union 
of  the  open  ends  by  two  rows  of  suture  through  the  serous 
coat.  In  appl}dng  the  sutures  care  must  always  be  taken 
not  to  transfix  the  mucous  coat. 

When  adliesions  exist  high  up,  the  abdominal  incision  must 
be  extended.  This  is  best  done  T^dth  the  ovariotomy-scissors 
(page  92).  I  have  never  seen  delayed  union  in  a  wound 
made  by  scissors.  The  senior  assistant  should  guard  the 
viscera,  as  the  wound  is  being  extended,  by  pushing  his  left 
forefinger  upwards  below  the  point  of  the  lower  blade  of  the 
scissors.  As  the  point  is  perfectly  blunt,  there  will  be  no  fear 
of  the  finger  being  wounded.  A  flat  sponge  is,  of  course,  the 
best  guard  when  it  can  be  applied,  as  in  cases  where  the 
tumour  is  simply  large  or  soUd,  but  under  the  circumstances 
now  described  this  cannot  always  be  done  omng  to  the  high 
adhesions.  The  operator  must  keep  to  the  middle  line — a 
simple  task,  for  by  passing  the  blades  into  the  upper  angle  of 
the  wound,  the  recti  wall  fly  apart  as  he  cuts  through  the  walls, 
so  that  if  he  does  not  cut  too  fast  he  can  easily  see  where  he  is 
going.  If  he  be  too  precipitate,  he  may  wound  one  of  the  recti, 
but  he  can  readily  find  the  right  track  again,  along  the  linea 
alba.  Perhaps  he  may  prefer  to  guard  the  cyst  and  other 
structm-es  himseK  by  keeping  his  left  fore  and  middle  fingers 
under  the  lower  blade  of  the  scissors,  raising  the  walls  as  he 
cuts ;  this  is  best  if  his  assistant  be  inexperienced.  I  have 
never  seen  any  injury  to  the  deeper  structures,  but  in  one  case, 
in  England,  the  intestine  was  wounded  and  an  artificial  anus 
resulted. 


215 


CHAPTEE  VIII. 

THE   OPERATION   OF   OVARIOTOMY. 

{Continued.) 

Ligature  of  the  Pedicle. — A  pedicle  being  found,  it  will 
now  be  necessaiy  to  secure  it  by  ligature.  The  typical  pedicle 
is  easily  recognized,  tbe  enlarged  Fallopian  tube  presenting  a 
characteristic  appearance  (Fig.  98).     When  the  pedicle  is  broad 


Fig.  98. — A  Long  Pedicle. 

The  cyst  has  been  tapped  aud  is  collapsed.     The  vessels  in  the  outer  border  of 
the  pedicle  are  indicated.     (Semi-diagrammatic.) 

and  thin,  the  operator  may  pass  his  finger  down  it  till  he  can 
detect  the  uterus,  should  that  organ  be  out  of  sight.  When  the 
pedicle  is  very  broad,  it  is  important  to  ascertain  the  precise 
relations  of  the  uterus  to  the  cyst.  In  the  shortest  and  broadest 
kind  of  pedicle,  the  base  of  the  cyst  will  be  found  close  to  the 
side  of  the  uterus,  separated  from  that  structure  by  a  short 


216 


THE    OPERATION    OF    OVARIOTOMY. 


segment  of  the  broad  ligament  (Fig.  99),  or,  in  some  cases, 
actually  touching  uterine  tissue.  The  fundus  uteri  mil,  in 
such  a  case,  be  considerably  displaced  to  the  opposite  side. 
This  displacement  is  easy  to  understand,  for  the  base  of  the 
distended  cyst,  lying  in  almost  immediate  contact  with  the  side 
of  the  utenis,  and  unable  to  rise  high  out  of  the  pelvis,  must  press 
heavily  on  the  organ.  When  the  pedicle  is  long,  this  displace- 
ment does  not  necessarily  occur,  the  cyst  rises  out  of  the  pelvis, 
and  its  base  simply  hes  over  the  fundus  of  the  uterus. 


Fig.  99. — A  Shokt,  B:ioad  Pedicle.     {Scmi-diajrammaf.ic.) 


In  examining  the  region  of  the  pedicle  any  pelvic  adhesion 
must  be  taken  into  account.  An  atrophied  second  pedicle, 
the  tumoiu-  consisting  of  two  cystic  ovaries  fused  together,  may 
be  taken  for  an  adhesion.  I  have  seen  this  condition  at  several 
operations,  and  it  was  just  at  this  stage,  and  never  earlier,  that 
the  true  pathology  of  the  case  was  detected.  By  feeling  and 
inspecting  the  adhesion,  its  attachments  will  be  discovered. 
Should  it  be  found  that  the  apparent  adhesion  runs  to  the 
side  of  the  uterus  opposite  to  the  pedicle  already  in  sight,  the 
condition  just  described  will  probably  exist,  and  its  existence 
can  be  proved  by  examination  of  the  relations  of  the  Fallopian 
tube   and   broad   ligament.     Being   proved  to  be  a  pedicle,  it 


LIGATURE    OF    THE    PEDICLE — PELVIC   ADHESIONS.  217 

must  be  treated  as  such.  The  pedicle  first  cliscovered  should  be 
first  secured. 

When  the  suspected  pelvic  adhesion  proves  to  be  a  true 
adhesion  to  neighbouring  viscera  or  peritoneum,  then,  if  very 
thin,  it  will  be  sufficient  to  tie  it  with  a  piece  of  No.  1  silk,  and 
to  sever  it  with  a  pair*  of  scissors,  on  the  distal  or  tumour  side  of 
the  hgature.  If  broad,  yet  long  enough  to  allow  of  such  a 
manipulation,  it  should  be  transfixed  by  means  of  a  small 
pedicle-needle,  armed  with  No.  1  or  No.  2  silk,  and  secured  just 
as  the  pedicle  is  secured,  after  the  manner  presently  to  be 
explained.  Then  a  pair  of  pressure-forceps  must  be  made  to 
grasp  the  adhesion  on  the  distal  side  of  the  ligatm-e.  Lastly, 
the  adhesion  is  cut  across  between  the  ligature  and  the  forceps. 
The  object  of  the  forceps  is  to  prevent  haemorrhage  from  the 
distal  side  of  the  adhesion.  This  would  not  necessarily  be 
dangerous,  but  the  blood  would  run  into  Douglas's  pouch,  and 
although  not  difficult  to  remove,  its  presence  there  might 
puzzle  the  operator.  When  blood  is  found  in  Douglas's  pouch, 
it  is  not  always  easy  to  remember  whence  it  came.  So  the  less 
of  it  there  the  better,  and  the  more  precautions  the  operator 
takes,  from  the  first,  to  avoid  haemorrhage,  the  less  trouble  will 
he  encounter  later  on. 

When  the  pelvic  adhesions  are  very  broad,  short,  and  intimate, 
a  practicable  pedicle  existing,  then,  as  in  the  case  of  strong 
abdominal  adhesions,  it  is  best  to  secm^e  the  pedicle  first. 

Before  coming  to  the  direct  treatment  of  the  pedicle,  I  must 
once  more  remind  the  surgeon  that  he  may  find  that  the 
tumoiu-  is  not  sessile,  and  that  there  is  no  pedicle  at  all.  In 
such  a  case  he  must  have  discovered  parietal  or  intestinal,  or  at 
least  omental,  adhesions,  for  the  tumour  could  not  exist  without 
its  blood-supply.  (Fig.  100).  This  condition  is  apt  to  startle 
inexperienced  operators;  they  may  even  fear  that  they  have 
torn  through  a  pedicle.  This  accident,  however,  would  entail 
serious  haemorrhage,  which  would  only  too  soon  make  itself 
apparent.  When  the  pedicle  is  missing,  the  nature  of  the  case 
may  be  proved  by  passing  the  hand  along  the  sides  of  the 
uterus.  Then,  if  an  entire  appendage  be  wanting,  the  truth 
will  be  revealed.  Sometimes,  in  these  cases,  the  proximal  end 
of  the  pedicle  is  reduced  to  a  mass  of  fatty  or  fibrous  tissue. 


218 


THE    OPEKATION    OF    OVARIOTOMT. 


ending  in  an  irregular,   cord-like    structure,  the  sole    relic  of 
tube  and  broad  ligament.     (Fig.  101). 


Fig.  100.— a  Dermoid  Cyst  sepakated      Fig.  101. — Stump  of  the  Pedicle 
FKOM  its  Pedicle  and  nourished  by  from  the  same  case. 

Omental  Adhesions.     {Author.) 

Now  tbe  pedicle  itself  must  be  considered.  Wlien  toasted, 
or  reduced  to  a  mere  cord,  almost  devoid  of  vessels,  a  single 
ligature  of  No.  2  or  No.  3  silk  may  safely  be  tied  around  it. 
Even  in  sucti  a  case,  however,  the  surgeon  must  be  very 
judicious  about  trusting  to  single  ligatiu'es. 

It  is  with  a  good,  long,  and  tolerably  broad  pedicle  that  the 
operator  has,  as  a  rule,  to  deal.  Mathematical  rules  about 
cutting  it  long  or  short  cannot  possibly  be  framed  for  the 
benefit  of  the  inexperienced.  The  operator  must  be  guided  by 
the  dictates  of  common-sense.  It  is  evident  that  the  ligature 
needle  must  not  be  thrust  tlii'ough  the  pedicle  deep  down  and 
close  to  the  uterus,  nor,  on  the  other  hand,  so  near  the  cyst  as 
to  leave  a  stump  several  inches  in  length. 

The  ordinary  pedicle  will  consist  of  a  plane  surface,  two  or 
three  inches  wide,  and  about  the  same  length,  representing  the 
tube,  always  conspicuous,  the  broad  ligament,  the  ovarian 
ligament,  which  may  or  may  not  be  readily  detected,  and  lastly, 
an  elevated  ridge,  nmiiing  from  the  back  and  outer  part 
of  the  plane,  upwards,  outwards,  and  backwards  towards  the 
lumbar  region.     This  ridge,  whic-li  forms  the  outer  border  of  the 


LIGATL'RE    OF    THE    PEDICLE.  210 

pedicle,  is  filled  with  the  large  veins  forming  the  pampiniform 
plexus  and  the  ovarian  artery.  It  represents  the  normal 
infundilmlo-pelvic  ligament  (see  pages  27,  35,  37,  38). 

Dr.  Bantock  and  some  other  operators  invariably  compress 
the  pedicle,  before  applying  the  ligatm-e,  by  means  of  a  large 
pressm-e-forceps  with  bent  blades  applied  to  the  distal  side  of 
the  point  to  be  transfixed  by  the  pedicle-needle.  This  com- 
presses the  tissues,  so  that  the  ligature  can  be  drawn  more 
firmly  and  safely,  provided  that  the  assistant  takes  off  the 
forceps  at  the  moment  that  the  operator  begins  to  tie  the 
threads.  In  oophorectomj','  this  practice  is  always  advisable ; 
but  in  ovariotomy  it  may  cause  difficulties  to  inexperienced 
operators  and  assistants. 

The  surgeon  now  takes  in  his  right  hand  a  small  pedicle- 
needle  armed  with  No.  2  silk.  He  then  raises  the  outer  edge  of 
the  pedicle  with  his  left  thumb  and  forefinger.  The  vessels  are 
now  pushed  outwards,  and  the  needle  is  made  to  transfix  the 
tissues  of  the  outer  edge  on  the  inner  side  of  the  vessels,  at  the 
same  level  as  the  operator  thinks  right  for  the  future  ligature 
of  the  main  part  of  the  pedicle.  He  must  take  care  not  to 
transfix  any  vessels.  This  may  be  avoided  by  gently  sti^etching 
the  tissues  of  the  pedicle,  entering  the  point  of  the  needle  on 
the  outer  side,  and  watching  its  egress  on  the  inner  side.  The 
point  may  then  be  seen,  possibly  threatening  a  vessel.  It  must 
be  safely  guided  through,  awaj^  from  that  vessel.  In  some 
cases,  a  stout  cuiwecl  sutiu^e-needle  answers  better  than  a 
pedicle-needle  for  the  present  purpose.  The  operator  will 
know,  at  the  time,  which  will  prove  the  more  handy. 

The  ligatiu^e-silk  must  now  be  di'awn  through,  not  in  a  loop, 
and  the  ends  tied  tightly  on  the  outer  side  of  the  pedicle.  In 
pulling  them,  when  the  operator  feels  that  the  tissues  are 
yielding,  he  may  be  sure  that  he  has  pulled  tightly  enough. 
He  must  avoid  snapping  the  silk,  a  troublesome  accident  which 
may  usually  be  prevented.  Mr.  Thornton  leaves  this  ligatiu'e 
untied  in  anaemic  patients  till  the  main  part  of  the  pedicle  has 
been  secured.  He  believes  that,  as  this  permits  the  retiu^n  of 
much  blood  through  the  veins  into  the  general  circulation,  it 
may  avoid  loss  of  blood.  For  blood  taken  away  in  the  tumom^ 
is,  pln^siologicalh'-,  blood  which  is  shed. 


220 


THE    OPERATION    OF    OVARIOTOMY. 


The  main  part  of  the  i^edicle  must  next  be  transfixed.  The 
pedicle  is  carefully  raised  by  the  operator's  left  fingers  and 
thimib.  A  stout  pedicle-needle  (page  113),  armed  with  No.  3 
silk,  is  thrust  through  the  j)edicle  with  care  and  deliberation. 
The  operator  must  take  the  same  precautions  as  when  engaged 
in  secm'ing  the  outer  edge  of  the  pedicle.  The  moment  that 
the  loop  of  the  ligatm'e  appears  as  the  point  of  the  needle 
passes   through   (Fig.    102),  it  must  be  seized  by  the  senior 


^^^^^^a^oK 


Fig.  102. — Ligature  of  the  Pedicle. 
Transfixion  with  the  needle.* 


assistant,  who  may  hook  his  right  forefinger  into  it.  The 
operator  then  withdi-aws  the  needle.  By  the  above  manoeuvre 
the  needle  is  not  thrust  through  the  pedicle  to  an  unnecessary 
extent. 

The  operator  may  now  tie  the  ligatm-es  after  the  method  of 
Sir  Spencer  Wells,  or  of  Mr.  Tait.  Perhaps  the  simplest  and 
easiest  method  is  that  explained  by  Fig.  103.     One  end  of  the 


Fig.  103. — Ligature  of  the  Pedicle. 
One  end  of  the  thread  passed  through  the  loop. 

silk  is  brought  half  round  the  pedicle,  passed  through  the  loop 
which  is  not  to  be  cut  tlu'ough,  and  then  tied  to  the  other  end 
of  the  silk  round  the  opposite  half  of  the  pedicle.     Thus  the 

*  All  these  sketches  representing  the  process  of  ligature  of  the  pedicle  are 
diagrammatic.  The  thickness  of  the  pedicle  is  indicated,  and  the  ligatured 
outer  border  is  also  represented  in  three  of  the  drawings. 


LIGATURE    OF    THE    PEDICLE.  221 

pedicle  will  be  firmly  held  by  two  loops.  This  is  an  excellent 
and  exceedingly  simple  method,  always  employed  by  Dr. 
Bantock.  In  tightening  the  ligature,  the  ends  must  be  pulled 
steadily  and  firmly,  and  in  one  direction  throughout,  else  the 
silk  may  get  frayed  and  snapped  as  it  passes  through  the  loop, 
or  the  loop  itself  may  be  cut.  An  accident  of  this  kind  is  not 
unfrequent  when  the  surgeon  is  inexj)erienced.  The  intend- 
ing operator  should  practise  this  method  with  a  loop  of  twine 
passed  through  a  towel ;  he  will  then  understand  how  to  avoid 
fraying  the  ligatm-e  against  its  own  loop  as  it  is  being  tightened. 
This  loop  is  highly  suitable  for  oophorectomy. 

In  this,  and  in  any  other  method,  the  senior  assistant  must 
hold  up  the  flaccid  tumour  firmly  and  to  one  side  during  the 
application  of  the  ligatures.  Whilst  the  operator  is  drawing 
the  knots  tight*  the  assistant  must  never  neglect  to  relax  the 
pedicle  by  ceasing  to  drag  on  the  tumour. 

There  is  yet  another  method  very  easy  to  carry  into  practice; 
it  answers  all  ]3urposes  admirably.     The  loop  (Fig.  102)  must 


Fig.  104. — Ligature  of  the  Pedicle. 
The  loop  cut  and  the  threads  crossed  on  one  side. 

be  cut  through.  Then  two  threads  will  lie  in  the  pedicle.  The 
operator  and  assistant  make  sure  of  the  right  ends  of  the 
threads,  and  then  the  operator  twists  the  end  of  the  thread 
intended  for  the  outer  loop  round  the  corresponding  end  of  the 
remaining  thread  (Fig.  104).  The  importance  of  this  pre- 
caution has  been  explained  at  page  187,  where  Fig.  92 
demonstrates  the  danger  which  its  omission   may  entail.     It 

*  Sir  Spencer  Wells  and  all  the  surgeons  at  the  Samaritan  Hospital,  including 
myself,  invariably  tie  in  a  "double  reef"  or  "surgeon's  knot."  "This  is  made 
by  passing  one  end  of  the  thread  twice  over  the  other  before  turning  each  end 
back  again  to  form  the  second  noose"  (Fergusson,  System  of  Practiced  Surgery, 
4th  ed.,  p.  33  and  Fig.  38).     It  is  easily  applied  and  very  safe  for  this  purpose. 


222  THE    OPER\TIOX    OF    OVARIOTOMY. 

must  only  be  clone  on  one  side  of  the  pedicle.  The  two  ends 
of  one  thread  are  then  tied  fii-mly  on  the  outer  side  of  the 
pedicle,  care  being  taken  that  the  loop  slips  into  the  groove 
occupied  by  the  ligature  already  applied  to  the  outer  border. 
The  ends  of  the  remaining  thread  are  then  tied  arouml  the 
inner  side  of  the  pedicle.  If  the  pedicle  be  short,  the  surgeon 
must  be  cautious,  as  he  may  be  compelled  to  tie  uterine  tissue, 
which  requires  very  firm  ligature  (page  17). 

These  loops  must  be  drawn  firmly,  so  that  the  tissues  on  the 
distal  and  proximal  side  bulge  over  and  touch  each  other.  The 
advantage  of  this  condition  has  already  been  ex2:)lained ;  but 
the  surgeon  must  be  cautious  about  drawing  the  ligatures  too 
firmly.  A  triumphant  jerk  at  the  end  may  easily  snap  the 
ligature,  nor  is  the  silk  always  trustworthy,  however  slowly 
and  catefuUy  the  operator  may  pull  it  tight.  The  breaking 
of  the  ligature,  under  these  circumstances,  is  most  untoward, 
and  involves  jet  more  trouble  and  danger  than  when  it 
occurs  during  the  ligature  of  the  outer  edge  of  the  pedicle.* 

When  the  pedicle  is  very  broad,  a  second  or  even  a  third 
transfixion  will  be  necessary.  The  second  transfixion  must 
thus  be  performed:  The  thread  for  the  outer  loop  [a,  Fig.  105) 
is  twisted,  on  one  side  of  the  pedicle,  round  the  other  thread 
(b)  as  described  above  ;  then  the  outer  loop  is  tied.  The  pedicle- 
needle  is  then  threaded,  first  with  a  single  ligature  (c), 
and  then  with  one  end  (b)  of  the  untied  thread  ah*eady 
passed  through  the  pedicle.  The  transfixion  is  then  per- 
formed (Fig.  105). 

This  second  threadino-  and  transfixion  is  best  mnnaored  with 
the  assistance  of  the  long,  free  (or  mihandled)  pedicle-needle, 
for,  as  has  been  explained  in  describing  that  instrument  at 
page  114,  its  large  eye  is  suited  for  the  present  purpose. 
Re-threading  a  curved,  handled  needle,  in  the  middle  of  the 
operation,  is  often  a  troublesome  process. 

*  I  will  not  dwell  here  on  Sir  Spencer  Wells'  controversy  on  the  f|iie3tion  of 
the  necessary  tightness  of  the  ligature.  (See  Diaiinosis  and  Sair/ical  Treatment 
of  Abdominal  Tumours,  1885,  p.  92,  and  author's  Tumours  of  the  Ovary,  p.  151.) 
Sir  Spencer  says  : — "  I  always  tie  as  tightly  as  I  can."  If  he  did  so  he  would 
certainly  snap  the  ligature,  and  so  would  anybody  whose  hamls  were  not  very 
weak.  He  means  that  he  always  ties  the  ligatures  as  tightly  as  his  manipulative 
in.stinct,  the  residt  of  long  experience,  knows  to  be  sulficient  for  its  jmrjiose. 


LIGATURE    OF    THE    PEDICLE. 


223 


The  third  thread,  c,  must  be  once  twisted  round  the  second, 
h  ;  this  is  best  done,  perhaps,  on  the  side  where  h  forms  a  loop 
(see  Fig.  105).  Then,  on  the  opposite  side,  the  two  free  ends 
of  the  second  thread,  h,  are  firmly  tied.  The  ends  of  the  third 
thread,  c,  are  then  tied  on  the  inner  side  of  the  pedicle.  The 
threads  will  then  lie  as  in  Fig.  106.  Thus  the  three  threads, 
firmly  interlocked,  will  hold  the  pedicle  tightly. 


<■  h 

Fig.  105. — Ligature  of  the  Pedicle. 
Double  transfixion,  showing  how  the  threads  are  to  be  crossed. 


Fig.  106. — Ligature  of  the  Pedicle. 
Double  transfixion  :  the  threads  tied,  as  seen  on  a  side  view  of  the  pedicle. 

Should  a  third  transfixion  be  required,  the  third  thi'ead, 
instead  of  being  tied,  must  be  threaded  on  the  needle  in 
company  with  a  fourth,  and  the  process  just  described  will 
be  repeated.  Care  must  be  taken  not  to  neglect  interlocking 
the  threads  once  more,  as  before. 

When  any  loop  is  tied,  in  the  course  of  the  above  manipula- 
tions, the  ends  of  the  threads  must  be  cut  short ;  if  all  the 
threads  be  left  uncut  imtil  the  ligatm-e  is  complete,  much 
needless  confusion  may  be  entailed. 


224  THE    OPERATION    OF    OYAKIOTOMY. 

In  order  to  make  assiu'ance  doubly  sure,  it  is  advisable 
to  bring  the  two  ends  o£  the  inner  ligature  round  the  entire 
pedicle,  and  to  tie  them  once  more,  taking  great  care  that  the 
ligatiu-e  sinks  into  the  groove  already  formed  by  the  threads. 
In  tying  this  final  knot,  each  end  of  the  thread  must  be 
pulled  back  from  the  first  knot,  which  mil  thus  be  made 
tighter.  If  the  ends  be  crossed  over  the  knot  it  may  be 
loosened  as  the  second  knot  is  tied.  Thi'ough  fear  of  such 
an  accident,  o^Ning  to  inadvertence,  many  operators  object 
to  bringing  the  ends  of  the  inner  thread  round  the  pedicle. 
They  tie  a  fresh  thread  round  the  pedicle,  taking  care  to  let 
it  sink  in  the  groove  formed  by  the  other  threads. 

A  pressure-forceps  is  now  fixed  to  the  inner  and  another  to 
the  outer  border  of  the  distal  side  of  the  pedicle,  about  half  an 
inch  from  the  ligature-groove.  This  must  always  be  done,  and 
on  no  account  shoidd  only  one  pair  be  applied.  A  single  pair, 
made  fast  to  one  side,  mil  not  be  safe,  for  whilst  the  assistant 
holds  it  fii-mh^  dui'ing  the  sponging  of  the  peritoneum,  the 
pedicle  may  be  dragged  upon,  and  the  hgature  consequently 
strained  in  one  direction.  The  pedicle  is  now  cut  across 
with  scissors  about,  or  rather  less  than,  one  inch  beyond  the 
ligature-groove.  I  have  already  referred  to  this  step  at  page 
92,  in  describing  the  use  of  the  scissors.  Whilst  this  is 
being  done,  the  assistant  or  nurse  must  carefully  support  the 
tumour,  so  that  it  does  not  dxag  and  tear  itself  off  when 
half  divided. 

The  senior  assistant  takes  hold  of  the  two  forceps  attached  to 
the  pedicle  directly  it  is  cut  across,  and,  letting  the  stump  sink, 
gi'asps  them  by  the  bows  in  one  hand  until  the  operator  wishes 
them  removed,  or  desires  for  any  reason  that  the  assistant 
should  let  go  of  them.  The  operator,  under  the  latter  circum- 
stances, may  place  the  handles  of  the  forceps,  within  the 
abdominal  cavity  with  little  risk,  since  anything  which  has 
b39n  attached  to  the  pedicle  is  not  likely  to  be  forgotten. 
Forceps  should  not  be  so  placed  under  any  other  condition, 
if  it  can  possibly  be  avoided.  If  left  attached  to  omentum, 
they  are  very  ajjt  to  be  overlooked  at  the  end  of  the  operation. 

The  moment  that  the  tumour  has  been  cut  away,  a  large  flat 
sponge  must  be  slipped  into  the  abdomen  imder  the  upper  part, 


DIA^SION    OF    THE    PEDICLE EISCAPSULED    CYSTS.  225 

and  above  the  upper  limit  of  the  abdominal  wound.  The 
operator  raises  the  upper  angle  of  that  wound  by  hooking  it_ 
up  with  his  left  forefinger,  as  he  pushes  in  the  sponge  with  his 
right  hand.  The  peritoneum  in  the  front  of  the  pelvic  cavity, 
Douglas's  pouch,  and  the  lumbar  region  must  be  cleaned  with 
sponges.  The  senior  assistant  then  washes  away  the  blood,  etc., 
from  the  abdominal  integuments,  and  the  waterproof  sheet, 
taking  care  to  clean  the  latter  last,  and  not  to  use  the  sponge 
which  has  been  scoured  over  it,  to  wipe  any  structure  near  the 
seat  of  operation.  Both  operator  and  assistant  should  now  wash 
their  hands  and  forearms  in  carbohzed  water.  It  may  happen 
that  the  tumour  has  two  pedicles,  being  made  up  of  two  cystic 
ovaries  fused  together  {see  page  216).  In  such  cases,  the  second 
pedicle  must  be  secured  after  the  manner  of  the  first,  unless  it 
be  so  atrophied  that  it  may  be  safely  tied  by  a  single  No.  3 
silk  ligature. 

When  the  pedicle  is  distinct,  but  exceedingly  short,  so  that 
manipulations  must  be  carried  on  close  to  the  uterus,  the 
large  pressure-forceps  should  be  applied  to  it,  or  even,  when 
the  shortness  is  extreme,  to  the  base  of  the  cyst  beyond  the 
pedicle,  so  that  room  is  left,  between  the  forceps  and  the 
uterus,  for  securing  the  outer  vessels,  transfixion,  and  hgature. 
As  the  first  of  the  transfixing  ligatures  is  being  tied  by  the 
operator,  the  assistant  must  take  off  the  forceps.  This  process 
is  constantly  resorted  to  in  oophorectomy. 

DifB.culties  respecting  the  Pedicle  or  other  rela- 
tions of  the  Tumour. — Before  proceeding  further,  I  must 
note  certain  conditions  which  are  sometimes  discovered  at  the 
pedicle  stage,  as  it  may  conveniently  be  termed,  of  the  opera- 
tion. There  may  be  no  true  pedicle,  or  the  tumour  may 
prove  irremovable. 

Treatment  of  Sessile  Tumours. — The  surgeon  must  be  careful 
to  distinguish  between  deep  pelvic  adhesions  and  absence  of  a 
pedicle.     A  new  surgical  problem  has  then  to  be  faced. 

Micfqjsuled  Ovan'cDi  Cysts. — On  exposing  or  on  tapping  an 
ovarian  cyst,  it  may  be  found  that  the  cyst-wall  is  invested 
in  front  by  a  capsule,  generally  of  a  very  pale  red  coloiu-,  and 
contrasting  strongly  with  the  white  cyst- wall  behind  it.  The  cap- 
sule is  formed  by  the  distended  layers  of  the  broad  hgament  into 

Q 


226  THE    OPERATION    OF    OVARIOTOMY. 

wHcli  the  tumour  has  forced  itself,  and  hy  peritoneum  detached 
from  adjacent  parts  of  the  pelvis.  When  we  remember  the 
intimate  relations  of  the  most  important  pelvic  viscera  to  the 
pelvic  peritoneum,  it  stands  to  reason  that  those  relations  are 
greatlv  distui'bed  when  a  cjst  burrows  under  the  serous  mem- 
brane beyond  the  limits  of  the  broad  ligament.  In  extreme 
cases  the  inferior  part  of  the  cyst  may  lie  below  its  serous 
capsule,  touching  the  pelvic  fascia,  and  in  close  proximity  to 
large  vessels,  the  ui'eters,  and  the  adjacent  viscera. 

"When  a  capsule  is  detected,  the  operator  should  di'aw  it 
upwards  with  the  cj'st-wall  after  the  ejst  has  been  tapped. 
He  may  then  find  that  capsule  and  all  can  be  removed  entire, 
there  being  enough  space  between  the  uterus  and  the  tumour 
to  form  a  true  pedicle.  This,  however,  is  rare ;  the  cyst  has 
generally  bm-rowed  deeply  in  the  manner  noted  above  ;  besides, 
the  cajDsule  may  be  intimately  connected  externally  with  im- 
portant structures.  When,  therefore,  on  drawing  up  the  capsule, 
it  is  found  to  be  deeply  connected  with  other  parts,  the  sm-geon 
must  not  venture  to  take  it  out  entii^e.  He  must  enlarge  the 
abdominal  w^ound,  and  carefully  shell  the  cyst-wall  out  of  the 
capsule.  This  can  be  done  by  gentle  traction  on  the  cyst, 
the  assistant  brushing  a  sponge  against  the  capsule  as  it  comes 
away.  Large  vessels  will  be  torn  through,  and  must  be  secured 
with  pressure-forceps.  Great  care  must  be  taken  that  the  cap- 
sule be  not  perforated  or  lacerated,  as  this  will  seriously  affect 
results.     This  process  of  enucleation  often  causes  much  shock. 

The  surgeon  can  generally  find  the  fundus  uteri  outside  the 
capsule  as  he  reaches  the  deep  part  of  the  tumoui'.  When  he 
succeeds  in  finding  the  fundus,  he  will  have  the  advantage  of 
a  valuable  landmark.  I  once  assisted  at  an  operation  where 
the  cyst  had  detached  the  whole  of  the  peritoneum  from  the 
back  of  the  uterus ;  thus  the  uterus  formed  part  of  the  an- 
terior, and  its  posterior  serous  investment  formed  part  of  the 
posterior,  wall  of  the  capsule. 

As  a  rule,  the  base  of  the  cyst  can  be  found  and  detached 
from  the  deepest  part  of  the  capsule  which,  inferiorly,  may 
be  no  longer  peritoneal,  but  formed  out  of  the  pelvic  fascia, 
as  above  described.  The  base  of  the  cyst  must  be  very  care- 
fully separated  from  its  attachments,  and  several  large  vessels 


ENUCLEATION    OF    A    SESSILE    TUMOUR.  227 

will  require  immediate  ligature  ;  they  can  generally  be  detached 
and  secured  before  division. 

The  management  of  the  empty  capsule  is  most  important. 
In  some  cases  its  deeper  part  can  be  transfixed  and  ligatured, 
as  though  it  were  a  normal  pedicle ;  the  ligature  may  include 
uterine  tissue  (pages  17,  222).  After  ligature  the  capsule  is  cut 
short,  and  its  free  edges  beyond  the  ligature  should  be  sewn 
together  by  a  continuous  No.  1  silk  suture.  In  one  case  where 
I  operated,  I  secured  the  capsule  in  this  way,  sewing  it  up  from 
the  side  of  the  pelvis  to  the  side  of  the  uterus  as  far  as  the 
stump  of  the  uterine  end  of  the  Fallopian  tube.  The  patient 
recovered  with  no  local  trouble  whatever.  In  many  cases  the 
base  of  the  capsule  lies  very  deep  in  the  pelvis,  and  cannot  be 
treated  in  this  manner.  As  much  of  the  capsule  as  possible 
must  then  be  raised  out  of  the  abdominal  wound,  so  that  the 
greater  j^art  can  be  cut  away,  the  remainder  being  left  be- 
hind and  drained.  When  the  upper  part  of  the  capsule,  or 
as  much  as  can  be  safely  pulled  forwards,  is  cut  away,  all 
bleeding  vessels  in  the  cut  edge  must  be  secui^ed  with  pressure- 
forceps  as  they  are  divided.  The  free  edge  is  then  attached 
by  suture  to  the  borders  of  the  lower  part  of  the  abdominal 
wall.  Bleeding  points  on  the  inner  surface  of  the  capsule 
are  secured  by  ligature,  and  then  search  is  made  to  make 
sure  that  the  capsule  is  not  lacerated  and  that  no  omentum 
or  intestine  protrudes  into  its  cavity ;  in  fact,  the  surgeon 
must  see  that  the  remnant  of  the  capsule  is  entirely  cut  off 
from  the  peritoneal  cavity.  Protruding  viscera  must  be  re- 
duced, and  holes  in  the  capsule  sewn  up.  This  should  be 
done  from  the  outer  or  peritoneal  side  of  the  capsule. 

Lastly,  a  glass  drainage-tube  is  passed  into  the  capsule.  The 
sutures  holding  the  edges  of  the  capsule  to  the  abdominal 
incision  are  tied,  then  the  peritoneal  cavity  above  the  capsule  is 
cleaned,  and  the  upper  part  of  the  abdominal  wound  closed. 
Drainage  must  be  conducted  on  the  usual  principles  (page  127). 

Irremovable  Base  of  Ci/st. — Sometimes  the  base  of  the  cyst 
itself  cannot  be  shelled  out  of  its  capsule.  It  must  then  be 
left  behind  and  sutured,  together  with  the  remains  of  the 
capsule,  to  the  edges  of  the  abdominal  wound,  and  di-ained. 
This  may  have  to  be  done  in  cases  of  non-encapsuled  cysts,. 


228  THE    OPERATION    OF    OVARIOTOMY. 

where  the  base  is  strongly  adherent.  The  operator  must 
endeavour  to  take  away  all  solid  growths  from  the  piece  of 
cyst  left  behind,  else  both  sepsis  and  recurrence  will  be  very 
probable. 

In  all  enucleations  and  divisions  through  capsules  and  cyst- 
walls  in  the  com-se  of  an  operation,  the  assistant  must  make 
free  use  of  the  sponges,  so  that  the  operator  may  see  his 
way.  A  great  number  of  pressm^e-forceps  will  be  needed, 
and,  when  all  used  up,  those  which  secm^e  the  largest  vessels 
should  be  removed  after  the  vessels  have  been  tied. 

Incomplde  Ovariotomy. — This  subject  must  be  considered  now, 
in  the  midst  of  the  details  of  the  complete  operation.  For  I 
am  endeavouring  to  describe  the  stages  of  ovariotomy  in 
their  natural  order,  making,  at  the  same  time,  allowance  for 
serious  contingencies  and  complications,  and  indicating  at 
what  stage  they  may  occur,  and  how  they  should  be  met. 
It  is  evident  that  nobody  undertakes  to  perform  an  incomplete 
operation.  Such  an  operation  represents  accidental  conditions 
which  he  may  meet  in  the  course  of  almost  any  ovariotomy 
where  the  tumour  is  partly  solid.  These  conditions  may  be 
recognized  very  early.  The  surgeon  may  detect  intimate 
adhesions  between  the  front  of  the  tumom-  and  important 
viscera ;  besides,  the  tumom-  itself  may  bear  an  ugly  malignant 
aspect.  Then  he  can  leave  the  adhesions  alone,  and  sew  up  the 
abdominal  wound.  Perhaps  he  may  be  tempted  to  tap  the 
tumom-,  and  to  break  down  adhesions,  or  he  may  find  intimate 
adhesions  at  the  back  and  base  of  the  tumoiu',  and  all  this  after 
he  has  broken  down  the  solid  contents  of  the  tumour.  Lastly, 
the  lower  part  of  the  tumour  may  be  of  a  nature  which  "v\ill  not 
permit  of  enucleation.  All  these  unfavoui'able  conditions  the 
ovariotomist  must  be  prepared  to  meet.  It  is  not  suificient  for 
him  to  feel  sure  that  he  can  separate  separable  adhesions,  and 
secm-e  a  pedicle  in  the  orthodox  fashion.  He  must  be  ready, 
never  to  surrender,  but  to  beat  a  retreat  in  as  good  order  as 
he  would  have  advanced  to  a  surgical  triumph.  It  is  a 
moral  duty  for  a  surgeon  to  play  the  difficult  part  of  a 
Xenophon,  whenever  circumstances  render  that  step  necessary. 
When,  about  the  stage  of  the  operation  now  under  considera- 
tion,  the   operator   feels   that   he   would    not   be   justified   in 


INCOMPLETE    OVARIOTOMY. 


229 


removing  the  tumour,  lie  must  first  check  all  lisemorrhage, 
securing  vessels  on  the  tumour  as  well  as  elsewhere.  He  must 
also  see  that  he  has  not  lacerated  intestine.  The  transverse 
colon,  when  strongly  adherent  to  the  upper  part  of  the  cjst,  and 
tightly  stretched  upon  it,  is  liable  to  be  inadvertently  torn.  All 
other  portions  of  adherent  intestine  which  have  been  separated 
must  be  carefully  inspected.  Then  the  back  of  the  tumour  and 
the  structures  behind  it  must  be  carefully  cleaned  with  sponges. 
The  abdominal  wound  will  probably  be  long,  in  a  case  of 
this  kind.  If  so,  the  upper  part  should  be  closed  by  sutures. 
The  lacerated  margins  of  the  rent  made  in  the  tumour  by  the 


Fig.  107. — An  Opened  Cyst  or  Cavity,  secueed  by  Sutukes  to  the 
Abdominal  Wound. 


trocar,  and  by  the  hand  of  the  operator  endeavom^ing  to  empty 
the  contents,  must  then  be  fixed  by  sutures  to  the  corre- 
sponding sides  of  the  wound,  which  must  be  left  open. 
In  fixing  the  tmnour  in  this  manner,  the  suture-needles 
must  be  passed  through  the  peritoneum,  about  a  quarter 
of  an  inch  from  its  cut  edge,  so  as  to  bring  that  membrane 
in  contact  with  the  cyst-wall.  The  wound  will  then  be 
entirely  cut  off  from  the  cavity  of  the  abdomen  (Fig.  107). 
This  practice  is  adopted  in  some  cases  of  pelvic  abscess  and 
extra-uterine  foetation. 


230  THE    OPERATION    OF    OVARIOTOMY. 

Sometimes  a  tumour  requiring  the  above  treatment  is  multi- 
locular.  In  such  a  case  it  is  achdsable  to  cut  and  clear  away 
everything  contained  in  those  loculi  which  the  sui'geon  has 
broken  open,  and  then  to  wash  the  walls  of  the  chasm  left 
behind  with  carbolized  solution,  or  with  strong  iodine.  Lastly, 
a  drainage-tube  must  be  inserted,  long  enough  to  tmch  the 
bottom  of  the  opened  space  in  the  cyst,  whilst  its  upper  orifice 
lies  in  the  lower  angle  of  the  wound.  The  ca"vdty  must  be 
washed  out  eveiy  four  hours,  or  oftener,  if  much  fcetid  fluid 
escape  from  it. 

Exploration  of  the  Ovary  opposite  the  Tumour. — 
The  operator  must  now  search  for  the  other  ovary,  provided,  of 
course,  that  he  has  met  with  no  complications  rendering  that 
step  unnecessary.  He  effects  his  object  by  passing  his  left 
forefinger  along  the  fundus  and  back  of  the  uterus,  and  then 
searching  with  it  in  the  direction  of  the  broad  ligament  on  the 
side  opposite  to  the  pedicle.  He  must  not  forget  to  make  use 
of  the  uterus  as  a  guide,  in  this  manner.  Any  attempt  to 
reach  the  ovary  direct,  unless  it  be  actually  in  sight,  as  is 
sometimes  the  case,  may  involve  unnecessary  distiu-bance  of 
intestine.  If  the  above  advice  be  taken,  the  ovary  is  generally 
reached  without  difficulty,  provided  that  it  be  healthy,  and  not 
involved  in  some  morbid  process,  the  result  of  old  or  recent 
pelvic  inflammation.  Should  this  be  the  case,  an  inexperienced 
operator  will  certainly  be  puzzled.  The  parts  will  be  very  hard 
to  recognize,  and  intestine,  tube,  broad  Hgament,  and  other 
structiu-es  may  be  flrmly  adherent  to  the  ovary,  and  may, 
perhaps,  completely  conceal  it.  Sometimes  the  finger  comes  to 
a  dead  stop,  the  pelvic  structures  being  embedded  in  some 
organized  inflammatory  deposit.  In  cases  of  this  kind,  the 
ovary  had  best  be  left  alone.  Attempts  to  break  doAvn  its 
morbid  connections  may  cause  troublesome  hsemorrhage,  and 
the  intestine  may  be  torn  or  the  tube  bm'st. 

If  the  broad  ligament,  tube,  and  ovary  can  be  reached, 
but  are  found  to  be  matted  together  by  old  inflammatory 
adhesions,  they  ought  to  be  removed.  This  should  certainly 
be  done  when  the  patient  has  been  troubled  with  great 
pain  in  the  iliac  fossas  and  loins,  and  other  symptoms  more 
likely    to    arise    fi'om    pelvic    inflammation    than    from    the 


EXPLORATION  OF  REMAINING  OVARY.  2-31 

presence  of  a  large  ovarian  cyst.  Tlie  operator,  in  fact,  will 
have  to  perform  an  oophorectomy.  It  will  be  a  comparatively 
easy  operation  under  these  circumstances,  as  the  abdominal 
walls  are  already  very  lax  since  the  removal  of  the  ovarian  cyst, 
and  the  pedicle  of  the  small  diseased  ovary  can  be  much  more 
safely  seciu'ed  than  in  cases  of  uterine  fibroid.  It  is  the  facility 
and  safety  with  which  oophorectomy  can  be  performed  under 
these  circumstances,  which  make  some  operators  couelude,  too 
hastily,  that  oophorectomy  is  an  easy  operation.  In  the  chapter 
on  the  subject,  I  note  the  reasons  why  that  operation  often 
proves  to  be  so  difficult. 

Supposing  the  operator  feels  a  big,  succulent  ovary,  then  he 
must  draw  it  up  to  the  level  of  the  abdominal  woimcl  and 
examine  it  carefully.  He  must  remember  that  the  ovary  in  a 
healthy  young  girl  or  a  robust  woman  who  still  menstruates  is 
a  very  different  thing  to  that  organ  as  seen  in  the  post-mortem 
room  of  a  large  general  hospital,  where  it  has,  as  a  rule,  been 
removed  from  the  body  of  a  sickly  hospital  patient  (see  page 
27).  Even  in  the  latter  case,  the  ovary  is  usually  larger  than 
in  a  dissecting-room  subject,  the  body  of  an  elderly,  imderfed 
pauper.  Yet,  owing  to  the  manner  in  which  the  surgeon 
learns  the  anatomy  and  pathology  of  the  ovary,  he  is  apt  to 
uncler-rate  its  normal  size.  A  follicle  about  to  burst  may  be 
as  big  as  a  filbert,  and  will  stand  out  very  prominently  from  the 
sm-face  of  the  ovary,  as  a  red  ill-conditioned  looking  mass  which 
the  siu'geon  must  not  mistake  for  incipient  malignant  disease. 

True  cystic  disease  is  not  highly  difficult  to  recognize  in  its 
incipient  form.  A  cyst  of  considerable  size  may  be  completely 
concealed  in  the  pelvic  cavity  until  detected  by  the  operator's 
forefinger  at  this  stage  of  the  operation.  It  must  be  drawn 
out  and  removed,  like  the  larger  tumour.  Of  course,  if  there 
be  the  least  difficulty  in  getting  it  out  of  the  abdominal  wound 
it  should  be  punctiu^ed  with  a  small  tapping-trocar  (page  105). 
Indeed,  tapping  is  always  advisable,  in  order  to  facihtate 
ligatm-e  of  the  pedicle.  When  the  pedicle  is  rather  deep,  the 
large  pressure-forceps,  elbowed  or  straight  as  seems  most  con- 
venient according  to  circumstances,  may  be  applied  to  the  base 
of  the  cyst  or  to  the  pedicle  close  to  its  attachment  to  the  cyst, 
and  the  ligature  passed  through  the  pedicle  on  the  proximal 


232  THE    OPERATIOX    OF    OVARIOTOMY. 

side  of  the  forceps.  The  process  of  ligature  must  be  performed 
with  as  great  care  as  when  a  large  tumom"  is  severed  from  its 
pedicle. 

As  a  rule,  however,  the  operator  will  find  the  ovary  healthy, 
small  or  perhaps  atrophied.  Having  drawn  it  upwards  to 
ascertain  that  fact,  he  then  pushes  it  down  again.  A  sponge, 
mounted  on  a  holder,  should  be  introduced  into  Douglas's  pouch 
with  the  left  hand  as  the  right  is  being  withdi-a-^-n,  as  the 
disturbance  of  the  pelvic  viscera  may  have  caused  fluid  to  run 
into  the  peritoneal  sjDace. 

The  oj)erator  must  be  cautious  about  meddhng  vdih  any 
fibroid  outgrowth  from  the  uterus  which  he  may  discover.  He 
shoidd  bear  in  mind  Six  Spencer  "Wells'  words,  "  In  one  case, 
after  completing  ovariotomj",  I  also  removed  a  fibroid  out- 
growth from  the  fundus  uteri.  This  patient  died,  and  I  think 
she  would  have  recovered  if  I  had  left  the  uterus  alone,  as  I 
have  done  in  several  cases  since,  where  the  size  of  the  growth 
was  insignificant."  If  the  patient  be  young  and  the  uterus  be 
studded  with  small  fibroid  outgro"^i:hs,  then  oophorectomy 
may  be  performed  by  simple  removal  of  the  remaining  ovary. 
In  one  of  my  own  ovariotomies,  I  thought  it  best  to  do  this, 
and  the  result  justified  my  resolution.  No  circumstances  could 
be  more  favourable  for  thorough  oophorectomy,  and  under  no 
conditions  is  that  operation  more  likely  to  effect  its  object  in 
arresting  morbid  uterine  development.  But  the  sm'geon  must 
not  enucleate  a  small  outgro^^i:h,  with  a  light  heart.  It  may 
cause  haemorrhage  so  severe  as  to  necessitate  clamping  the  uterus 
and  removal  of  its  body. 

Sometimes,  in  the  course  of  these  explorations  of  the  pelvic 
cavity,  previous  to  the  final  steps  of  the  operation,  the  body  of 
the  uterus  is  found  to  be  soft  and  enlarged.  This  may  lead  to 
a  suspicion  of  earl}'  pregnancy,  especially  when  there  has  been 
amenorrhoea,  nor  is  the  question  always  easy  to  decide  at  the 
time.  In  any  case  the  uterus  must  be  handled  very  gently,  and 
never  squeezed ;  then,  should  pregnancy  really  exist,  there  will 
not  be  much  danger  of  abortion. 

The  Introduction  of  Sutures  into  the  Abdominal 
Wound, — The  condition  of  the  opposite  ovarj'  having  been 
ascertained,  and  any  necessary  comphcation  in   this   dii'ection 


INTRODUCTION    OF    THE    SUTURES.  233 

]3roperly  encountered,  the  sutures  are  now  introduced  into  the 
abdominal  wound.  This  is  not  to  be  considered  as  the  last 
manoeuvre  in  ihe  course  of  the  entire  operation  ;  that  is  to  say, 
the  wound  is  not  to  be  closed  directly  the  sutures  are  introduced. 
The  large  flat  sponge  guarding  the  viscera  at  the  upper  angle 
of  the  wound  must  be  inspected.  If  any  portion  of  it  be 
covered  with  coagula  or  deeply  stained,  the  operator  must  search 
for  bleeding  points  in  the  direction  where  that  portion  lay. 
Unless  this  sponge  be  almost  dry  and  free  from  serous  effusion, 
it  must  be  taken  out  and  at  once  replaced  by  the  other  large 
flat  sponge.  Sometimes,  when  the  intestines  tend  to  protrude, 
it  is  safe  to  place  a  small  flat  sponge  over  them  before  introduc- 
ing the  sutures.  A  sudden  straining  effort,  which  is  likely  to 
occur  at  this  stage  when  the  chloroformist  may  have  neglected 
to  keep  the  patient  thoroughly  under  the  influence  of  the  anses- 
thetic,  will  endanger  the  viscera  as  the  needle  is  being  appKed 
to  the  inner  side  of  the  wound.  As  a  rule,  however,  the  lower 
part  of  the  large  flat  sponge  will  sufficiently  guard  the  exposed 
viscera.  It  is  only  when  the  wound  is  very  long  that  the 
second  sponge  becomes  necessary.  A  large  conical  sponge  should 
be  placed  in  Douglas's  pouch ;  the  beginner  had  better  fix  a 
sponge-holder  on  to  it.  If  adhesions  have  been  broken  down 
between  the  cyst  and  the  parietal  peritoneum  laterally,  a  flat  or 
round  sponge  should  be  placed  under  the  abdominal  walls  on  one 
or  each  side  of  the  wound.  The  two  pressure-forceps  may  now 
be  taken  off  the  pedicle,  and  it  is  best  to  cut  away  with  them 
the  small  pieces  of  pedicle  tissue  which  they  have  compressed. 
Before  the  two  forceps  are  removed  the  pedicle  must  be  carefully 
examined ;  any  pressure-forceps  remaining  on  vessels  in  the 
edge  of  the  abdominal  wound  may  safely  be  removed ;  it  is 
very  improbable  that  ligature  or  torsion  will  be  required.  The 
above  j)recautions  having  been  taken,  the  sm-geon  now  proceeds 
to  the  introduction  of  the  sutures.  If  the  edge  of  one  of  the 
recti  be  ragged,  through  a  bruise  from  the  handles  of  a  pressure- 
forceps,  the  torn  fibres  may  be  trimmed  with  scissors. 

The  surgeon  now  takes  one  of  the  needles,  attached  to  one- 
end  of  a  suture,  between  the  blades  of  the  needle-holder  (see 
page  115),  appHed  close  below  the  eye  of  the  needle,  with  the 
nozzle  directed  towards  its  point.     The  peritoneum  at  the  left 


234 


THE    OPERATION    OF    OVATIIOTOMY. 


side  of  the  upper  angle  of  the  wound  is  slightly  everted  hy  the 
operator's  left  thumb,  and  then  the  point  of  the  needle  is 
pushed  through  it  less  than  a  quarter  of  an  inch  from  its  cut 
horder  (Fig.  108).  Then  the  aponeiu'otic  structiu'es  are  trans- 
fixed, and  lastly  the  integuments,  so  that  the  needle  comes  out 
through  the  skin  about  a  Cjuarter  of  an  inch  from  the  margin  of 
the  abdominal  wormd.  The  needle  should  be  pushed  straight 
and  steadily,  then  it  will  go  easily  and  safely  through  the 
thickest  structures.  If  pushed  when  it  is  beginning  to  bend,  it 
will  probably  snap. 


Fig.  108. — Ovakiotomy  :  Ixtroductiox   of  Sutures   ixto  the  Abdominal 

WOUXD. 

The  needle  is  being  passed  through  the  peritonenm  ou  the  left  edf;e  of  the  wound. 

{After  Savage.) 

The  needle  attached  to  the  other  end  of  the  same  suture  is 
now  taken  up  in  the  holder.  The  peritoneum  at  the  right  side 
of  the  upper  angle  of  the  wound  is  everted  by  the  left  fore- 
finger and  transfixed,  together  with  the  more  superficial 
structures,  as  above  described.  The  needle  is  then  detached, 
and  the  assistant  takes  hold  of  the  two  ends  of  the  sutiu-e  in 
his  right  hand  and  pidls  them  a  little  upwards  and  forwards, 
pre\dously  pressing  the  sponge  between  the  hps  of  the  woimd 
with  his  left  hand.  This  sponging  j)roeess  should  be  repeated 
after  the  application  of  ever}'-  suture. 

A  sutm-e  is  then  passed  into  the  lower  angle  of  the  wound 
in  the  same  manner.  The  ends,  if  in  the  way,  may  be  held 
down  by  pressure-forceps.      Then  the  remaining  sutiu-es   are 


INTRODUCTION    OF    THE    SUTURES. 


235 


introduced  from  below  upwards,  at  intervals  of  about  half  an 
ineb.  They  must  be  made  to  lie  evenly  on  the  two  sides.  The 
nurse  must  be  ready  to  thread  some  more  sutures  should  the 
supply  appear  to  be  running  short. 

Some  operators  introduce  the  sutures  through  the  skin  on  one 
side,  and  inwards  till  the  peritoneum  is  transfixed,  and  then 
pass  the  needle  through  the  peritoneum  on  the  opposite  side, 
and    through    the   other  structures   outwards.      There   is   no 


Fig.  109. — The  Sutures  ix  the  Abdomixal  Wound. 

Showing  the   arrangement   described   in   the   text  (page  236)  for  cleaning  the 

abdominal  cavity,  without  the  risk  of  pulling  out  any  of  the  threads. 

serious  objection  to  this  method,  excepting  that,  perhaps,  when 
the  point  of  the  needle  is  much  blunted  by  thick  integu- 
ment, it  may  push  the  peritoneum  from  its  connections, 
instead  of  transfixing  it.  The  point  of  the  needle  is  also  apt 
to  run  into  the  flat  sponge,  and,  in  dark  weather,  it  may 
be  inadvertently  passed  through  a  bow  of  a  pressm-e- 
forceps  left,  for  some  reason,  in  the  abdominal  cavity.  These 
accidents,  especially  the  latter,  involve  waste  of  time.     The  less 


236  THE    OPERATION    OF    OVARIOTOMY. 

experienced  slionld  always  pass  the  siitm-es  fi"om  within  out- 
wards on  both  sides  of  the  wonnd. 

Arrangement  of  the  Sutures  for  the  further  Steps 
of  the  Operation. — "When  all  the  sutures  have  been  intro- 
duced, the  ends  are  gathered  together  on  each  side.  Each 
collected  set  should  then  be  firmly  grasped  close  to  the  ex- 
tremities of  the  thi-eads  b}^  a  pressui'e-forceps  (Fig.  109). 
This  arrangement,  introduced,  I  believe,  by  Dr.  Bantock, 
saves  a  great  deal  of  manipulation. 

The  operator  now  parts  the  sutures,  as  thej^  cross  between  the 
two  sides  of  the  wound,  with  his  fingers,  hooking  them  upwards 
and  downwards,  so  that  he  obtains  free  access  to  the  abdominal 
cavity  without  any  risk  of  pulling  out  a  sutm'e.  In  a  short 
wound  it  is  suificient  to  hook  upwards  all  the  sutm^es  except 
the  lowest  (Fig.  109).  Then  the  upper  angle  of  the  woimd 
is  raised,  the  sm'geon  doing  this  with  his  left  forefinger, 
which  should  also  hold  the  loops  formed  by  drawing  up 
the  middle  part  of  the  sutures. 

Cleaning  the  Abdominal  Cavity — "Toilet  of  the 
Peritoneum." — The  large  fiat  sponge  should  now  be  with- 
drawn. If  it  be  much  blood-stained,  the  abdominal  structures 
and  parietes  must  be  searched  once  more,  and  htemorrhage 
checked  by  ligatiu-e  with  No.  1  silk,  or  by  the  thermo- 
cautery. The  omentum  generally  requires  a  little  further 
judicious  scrutiny ;  ragged  or  thickened  portions  should  be 
ciit  away  after  the  ligature  has  been  apj^lied  above  them,  and 
care  must  be  taken,  as  has  been  already  remarked,  that  no 
holes  are  left  in  that  process  of  peritoneum. 

All  other  sponges  must  now  be  removed,  T\ith  the  same  pre- 
cautions— that  is,  bleeding  vessels  must  be  looked  for  when  a 
sponge  appears  much  blood-stained.  The  sponge  removed  fi-om 
Douglas's  pouch  must  be  carefully  inspected ;  then  a  sponge  is 
gently  passed  over  the  parietal  peritoneum,  and  Douglas's 
pouch  is  cleaned  by  another  sponge,  which  should  be  mounted 
on  a  holder.  If  the  sponging  be  done  roughly,  the  peritoneum 
will  be  irritated,  and  copious  oozing  of  blood-stained  serum  will 
rapidly  take  place. 

Flushing  the  Peritoneum. — Mr.  Tait  and  others  prefer 
to  wash  out  the  peritoneum  with  water  warmed  to  blood  heat. 


FLUSHING    THE    PERITONEUM — COUNTING    SPONGES.  237 

For  this  purpose,  the  lips  of  the  wound  are  held  wide  apart,  and 
the  water  is  poured  in*  from  a  pitcher.  The  fundus  of  the  uterus 
may  be  pushed  forwards  to  ensure  the  flushing  out  of  Douglas's 
pouch.  If  a  bleeding  vessel  remain,  its  position  will  be  indicated 
by  a  small  stream  of  blood  running  in  the  water  in  the 
abdominal  cavity.  The  water  should  be  poured  in  till  it  escapes 
clear.  It  is  extremely  serviceable  for  checking  capillary 
haemorrhage,!  and  when  the  wound  is  closed  the  temperature 
will  remain  at  blood  heat,  maintained  by  the  natural  heat- 
producing  agents  of  the  organism.  The  surgeon  must  always 
test  the  heat  of  every  pitcherful  before  emptying  it  into  the 
abdomen.  Cold  water  produces  great  depression,  and  is  a  bad 
haemostatic ;  water  too  hot  may  cause  fatal  damage  to  the 
serous  coat  of  the  intestines,  as  occurred,  I  am  informed,  in 
one  case  very  recently.  After  the  flushing  of  the  peritoneum, 
a  sponge  should  be  applied  to  Douglas's  pouch,  to  soak  up  any 
water  remaining  there.  This  flushing  process  is  always  ad- 
visable when  there  is  much  serous  oozing.  It  is  a  highly 
efficacious  method  for  detaching  clots  from  deep  parts. 

Counting  the  Sponges  and  Instruments. — Before 
tying  the  sutures,  the  operator  must  make  sure  that  no  sponges 
are  left  behind  in  the  peritoneum.  I  have  spoken  about  this 
danger  already  at  page  91.  A  sponge  may  have  fallen  into 
the  receptacle  for  the  ovarian  fluid,  or  may  be  lying  in  the 
pan  which  contains  the  tumour,  possibly  inside  the  cavity  of  the 
tumour  itseK.  It  may  be  lost  on  the  floor,  or  a  nurse  may  have 
mislaid  it  when  it  was  used  for  washing  the  hands  of  the 
operator  and  assistant  immediately  after  the  division  of  the 
pedicle.  A  sponge  may  also  have  been  torn  in  half,  and  if  the 
halves  be  counted  as  two  sponges,  another  sponge,  perhaps  left 
behind  in  the  abdomen,  may  be  overlooked.  I  have  heard  that 
nurses  have  been  seen  to  thrust  a  sponge  into  an  apron- 
pocket. 

On  the  other  hand,  when  much  sponging  is  needed,  the 
operator  may  very  naturally  forget  how  many  sponges  he  has 

*  It  must  not  be  allowed  to  trickle  in  slowly,  else  much  heat  will  be  lost ;  nor 
must  it  be  poui'ed  in  violently.  A  full  stream  must  be  steadily  emptied  into 
the  abdomen. 

+  See  Keetley,  op.  cit.  p.  204,  footnote. 


238  THE    OPERATION    OF    OVARIOTOMY. 

left  iu  the  body  of  tlie  patient.  The  assistant  may  have 
slipped  a  sponge  unawares  into  the  abdomen.  Lastly,  the 
nurse  may  be  careless,  and  may  reckon  one  more  sjDonge  than 
can  actually  be  accounted  for.  To  avoid  all  accidents  in 
respect  to  sponges,  they  must  be  counted  in  the  operator's 
presence,  at  this  stage. 

The  nurse  must  collect  the  sponges  in  a  large  bowl  or  basin, 
and  place  an  empty  bowl  by  its  side.  Then  she  must  take 
the  sponges,  one  by  one  and  not  in  pairs,  out  of  the  first 
bowl,  counting  audibly.  The  full  number  ought  to  be  at 
hand,  accounting,  of  course,  for  those  known  to  be  still  in 
the  patient's  body.  If  one  should  remain  unaccounted  for,  the 
set  must  be  counted  again.  Then,  if  it  be  not  found,  it  must 
be  searched  for  in  any  place  that  it  may  occupy  outside  the 
patient,  unless  the  operator  has  good  reason  to  believe  that 
it  is  in  the  peritoneal  cavity.  This  must  at  length  be  searched 
if  the  sponge  be  still  missing. 

The  inexperienced  operator  must  not  trust  too  much  to  his 
sense  of  touch.  The  bare  surface  of  a  sponge  is  not  always 
easy  to  detect  by  the  fingers  alone,  especially  when  soaked 
in  serum.  The  matter  becomes  very  troublesome  when  it  lies 
under  the  omentum,  a  not  unfrequent  hiding-place.  Hence 
that  fold  of  peritoneum  must  always  be  well  searched.  The 
hand  must  be  passed  under  the  parietes  towards  the  loins,  the 
epigastrium,  and  Douglas's  pouch.  In  the  course  of  the  above  pre- 
cautions, there  is  but  little  fear  that  the  sponge  will  not  be  found. 

The  same  precaution  is  necessary  mth  regard  to  pressure- 
forceps.  I  have  already  said  a  great  deal  on  the  subject  of 
these  instruments.  Strange  as  it  may  seem,  they  have  been 
left  behind  in  the  peritoneum  by  the  most  experienced  ope- 
rators. I  once  witnessed  an  accident  of  this  kind,  but  as  I 
was  administering  the  aneesthetic,  I  did  not  take  part  in  the 
counting  of  the  forceps  dimng  the  operation.  Afterwards, 
they  were  counted,  and  one  was  missing.  My  services  were 
at  once  called  for ;  the  patient  had  not  quite  recovered  from 
the  antesthetic,  the  wound  was  opened,  and  the  forceps  dis- 
covered, high  in  the  abdomen,  attached  to  the  omentum.  There 
were  no  untoward  results,  but  the  incident  caused  us  great 
mental  worry. 


COUNTING    THE    FORCEPS — CLOSURE    OF    THE    WOUND.       239 

The  forceps  should  be  counted  separately,  as  in  the  case  of 
the  sponges,  and,  if  missing,  must  be  searched  for  in  the 
same  manner.  They  are  very  apt,  owing  to  their  weight,  to 
fall  into  the  receptacle  for  the  ovarian  fluid ;  and  if  a  forceps 
should  drop  on  some  soft  solid  matter  from  the  ovary,  lying 
in  the  receptacle,  no  noise  is  heard,  and  its  fall  is  overlooked. 
They  may  also  be  carried  away  with  the  tumour,  to  which 
they  have  been  fixed  for  the  arrest  of  hsemorrhage  chmng  the 
separation  of  adhesions. 

Closure  of  the  Wound. — The  surgeon  having  made  sure 
that  all  the  sponges  and  forceps  have  been  removed  from  the 
abdominal  ca^dty,  the  pressure-forceps  holding,  on  each  side, 
the  collected  ends  of  the  sutm^es  (Fig.  109)  are  now  detached. 
The  assistant  holds  the  sutures  by  both  ends  in  his  left  hand. 
The  surgeon  then  takes  the  uppermost  suture  by  both  ends, 
the  assistant  sponges  the  edges  of  the  wound  immediately 
beneath  it,  and  then  the  surgeon  ties  it  in  a  reef  knot.  The 
suture  should  not  be  tied  in  a  double  reef,  or  "  surgeon's 
knot,"*  as  if  it  be  drawn  too  tightly,  which  is  very  probable, 
it  will  then  be  hard  to  loosen.  The  operator  must  take 
great  care  to  draw  the  suture  just  firmly  enough  to  bring  the 
edges  of  the  skin  into  apposition  without  the  least  tension, 
much  less  puckering.  Proper  adjustment  of  the  edges  of  the 
skin  ensures  perfect  union ;  excessive  tightness  of  the  sutm-e 
prevents  the  formation  of  the  firmest  possible  cicatrix.  The 
remaining  sutures  are  tied  in  the  same  way,  the  assistant 
taking  care  to  sponge  the  wound  before  each  thread  is  drawn, 
firmly.  The  ends  of  each  suture  should  be  cut  after  it  is 
tied,  and  must  not  be  left  more  than  a  quarter  of  an  inch 
long.  In  the  case  of  silkworm-gut  (page  120),  as  the  cut 
ends  are  stiff  and  apt  to  twist  about,  care  must  be  taken  that 
some  of  them  do  not  sink  between  the  edges  of  the  woimd. 
When  the  last  suture  is  tied,  if  the  skin  gape  at  one  or  two 
points,  superficial  sutm-es  may  be  applied ;  they  are  most 
readily  introduced  by  the  aid  of  a  stout  curved  needle. 

In  order  to  prevent  the  omentum  or  intestines  from  catch- 
ing in  the  sutures,  some  operators  direct  a  second  assistant  to 
grasp  the  edges  of  the  wound  between  the  sides  of  his  left 
*  See  p.  221,  footnote. 


240  THE    OPERATION    OF    OVARIOTOMY. 

thumb  'and  forefinger — the  most  convenient  manner  of  hold- 
ing the  parts  if  he  stand  at  the  left  hand  of  the  operator. 
This  mancBuvre  also  ensures  the  apposition  of  the  edges  of 
the  peritoneum.  Other  surgeons  prefer  to  leave  the  top  suture 
untied  till  after  the  others  have  been  secured,  so  that  the 
assistant  may  hold  it  upwards,  raising  the  abdominal  wound. 
Lastly,  some  leave  a  small  flat  sponge  in  the  wound  almost 
till  the  very  end,  pulling  it  out  before  the  last  three  or  four 
sutures  are  secured.  This  method  is  sure  and  simple,  but  the 
greatest  care  must  be  taken  lest  it  be  left  behind. 

Before  tying  the  last  suture,  the  sm-geon  must  press  his 
hand  gently  on  the  abdominal  walls  over  the  wound,  so  as 
to  expel  any  air  lying  in  the  peritoneal  cavity.  It  is  always 
important  to  bear  in  mind  how  many  sutures  have  been  in- 
troduced, especially  when  the  wound  is  long. 

Dressing  the  Wound  at  the  Close  of  the  Opera- 
tion.— When  Listerian  precautions  are  taken,  the  dressings 
should  be  thus  applied,  after  the  manner  recommended  by 
Mr.  Thornton : — The  wound  is  covered  with  a  pad  made  of 
six  or  eight  layers  of  carbolic  gauze,  cut  large  enough  to 
overlap  the  edges  of  the  incision  to  the  extent  of  an  inch 
in  all  directions,  and  damped  by  immersion  in  the  1  in  40  car- 
bolic solution.  Over  this,  three  or  four  larger  pads  are  placed, 
one  over  the  upper,  another  over  the  lower,  a  third  over 
the  right,  and  a  fourth  over  the  left  half  of  the  first  pad,  so 
as  to  cover  its  edges  and  surface  thoroughly.  A  big  pad, 
about  four  inches  broad,  is  placed  over  the  others,  so  as  to 
overlap  the  upper  and  lower  angles  of  the  wound  by  about 
two  inches ;  a  piece  of  pink  mackintosh  is  placed,  in  accord- 
ance with  Listerian  principles,  under  the  uppermost  layer  of 
this  pad,  so  that  blood  soaking  through  the  centre  of  the 
gauze  may  be  kept  from  contact  with  the  air.  This  pad 
must  not  be  too  broad,  else  it  will  not  lie  accurately, 
without  puckering,  over  the  abdomen  around  the  wound. 
The  spray  may  now  be  turned  off.  Straps  of  adhesive 
plaster  about  two  inches  broad  are  then  applied  over  the 
dressings,  being  fixed  at  each  end  to  the  integuments  of 
the  loins,  which  they  must  support  thoroughly.  The  skin 
must  not  be  puckered,  by  too  great  pressure  inwards,  at  the 


dressijSict  the  wound.  241 

parts  where  the  ends  of  the  strapping  are  applied.  This 
may  occur  if  the  surgeon  attempts  to  drag  the  skin  inwards 
by  traction  on  the  strapping  after  one  end  has  been  made 
fast.  If  the  abdominal  walls  be  very  relaxed  and  concave, 
as  after  the  removal  of  an  unusually  large  cyst,  layers  of 
cotton-wool  should  be  placed  over  the  dressings  so  as  to  fill 
up  the  hollow,  and  the  strapping  must  cover  the  wool. 
A  towel,  folded  once  on  itself,  is  placed  over  the  plaster 
so  as  to  overlap  the  lower  edge  of  the  dressing ;  the  flannel 
bandage  is  applied  over  this,  and  made  fast  by  means  of 
safety-pins. 

A  dressing  of  this  kind  may  be  left  untouched  for  a  week. 
In  the  meantime  the  possibility  of  discharge  soaking  through 
its  lower  border  must  not  be  overlooked.  The  lower  edge  should 
be  inspected  daily,  but  not  lifted  up.  After  the  sutiu-es  have 
been  removed,  a  thinner  gauze  dressing  is  laid  over  the  incision 
for  a  week.  The  wound  will  then  probably  be  healed ;  it 
should  be  supported  by  strapping  for  at  least  two  months. 

I  think  it  advisable,  in  any  case,  to  keep  a  -pad  of  gauze 
over  the  wound  so  as  to  protect  it  from  the  strapping. 
Portions  of  adhesive  plaster  may  block  the  orifices  of  the 
suture-tracks,  and  cause  small  abscesses  to  form. 

Surgeons  who  do  not  adopt  Listerian  precautions  make  use 
of  a  somewhat  simpler  dressing,  and  with  excellent  results. 
I  must  first  observe  that  the  wound  begins  to  unite  very 
rapidly,  so  as  to  cut  off  danger  of  septic  infection  fi-om  the 
peritoneal  cavity.  It  is  rather  towards  the  end  of  the  treat- 
ment that  care  is  particularly  necessary  in  the  di-essing  of 
the  wound,  for  any  lack  of  precautions  in  keeping  the  parts 
clean  may  cause  suppm-ation  in  the  tracks  of  the  sutures,  or 
even  along  the  edges  of  the  incision.  With  care  and  experi- 
ence, however,  the  wound  will  heal  in  the  most  satisfactory 
manner,  with  the  simplest  dressings,  provided  only  that  the 
broad  rules  ah'eady  indicated  be  duly  followed. 

A  few  layers  of  absorbent  gauze  are  placed  over  the  wound, 
in  the  manner  above  described.  A  large  woollen  pad,  en- 
veloped in  gauze,  and  sufficiently  wide  to  cover  the  front  of  the 
abdomen  without  puckering,  is  laid  over  the  other  dressings, 
and  a  many-tailed  binder  is  made  fast,  from  below  upwards, 

R 


242  THE    OPERATION    OF    OVARIOTOMY. 

over  the  pad.  The  sui'geon  must  follow  the  dii'ections  given 
at  page  180  for  the  proper  application  of  this  binder,  according 
to  certain  circumstances  which  are  there  noted.  This  bandage 
must  be  inspected  daily,  to  make  sure  that  it  does  not  slip 
upwards.  The  lower  part  of  the  di'essing  must  also  be 
watched,  lest  any  discharge  should  soak  through  it.  If  any 
be  seen,  fresh  gauze  should  be  applied  over  the  wound. 

Drainage. — When  this  measure  is  necessary,  the  glass  or 
india-rubber  tube  must  be  introduced,  and  the  wound  dressed 
in  the  manner  described  in  the  chapter  on  Instruments 
(page  126). 


243 


CHAPTER    IX. 

OVARIOTOMY:    AFTER-TREATMENT  AND   MANAGEMENT   OF 
COMPLICATIONS. 

Putting  the  Patient  to  Bed. — I  have  spoken  at  page 
189  of  certain  arrangements  with  regard  to  the  bed.  After  the 
operation,  the  patient  should  he  carefully  lifted  from  the  table 
and  laid,  on  her  back,  on  the  bed,  in  which  a  foot-warmer 
has  already  been  placed.  A  pillow  must  be  put  under  the 
knees,  and  three  or  four  are  neatly  arranged  to  receive  the  head 
and  shoulders,  which  must  not  lie  too  low.  The  bed  must  be 
protected  beneath  the  patient's  waist  by  a  mackintosh  covered 
with  a  draw-sheet  arranged  in  several  folds.  The  room  must 
then  be  cleared,  the  nurse  staying  by  the  patient's  bedside, 
whilst  the  operator  and  assistant,  with  the  under-nurses,  take 
away  the  instruments  and  appliances,  the  tables,  and  the 
receptacle  for  the  fluid. 

The  Instruments  after  Ovariotomy. — In  the  para- 
graphs on  the  trays  for  holding  the  instruments,  in  the  chapter 
on  Instruments  and  Appliances,  I  have  noted  that  the 
forceps,  needles,  and  other  implements,  not  excluding  the  trays 
themselves,  must  be  carefully  washed  clean  and  diied  directly 
after  operation  (page  85).  This  should  be  done  by  the  senior 
assistant  rather  than  by  a  nurse ;  and  when  the  operator  has 
seen  that  the  patient  is  lying  comfortably  in  bed,  he  should 
himself  superintend  the  process. 

Diet  after  Operation. — For  the  first  twenty-four  hom-s,  at 
least,  no  food  should  be  given  by  the  mouth.  To  relieve  sick- 
ness caused  by  the  anaesthetic,  the  mouth  may  be  rinsed  out 
with  lukewarm  water,  and  the  patient  may  suck  small  pieces 
of  ice.     In  healthy  young  subjects,  or  robust  women  of  mature 


244  OVARIOTOMY  :    AFTER- TREATMENl,    ETC. 

age,  notliing  more  will  be  needed  ;    aud  on  the  second  day, 
barley-water,  and  soda-water  with  milk  in  eqnal  proportions, 
may  be  sipped,  not  more  than    a   teaspoonful  being  taken  at 
a  time.     Some  patients  cannot  tolerate  cold  chinks ;    for  them 
warm   milk   will   be   beneficial,    and  a  few  di-achms  of  beef- 
tea   may   be   administered  from  time  to  time  on  the  second 
evening  after  operation.     "When,  however,  the  subject  is  feeble, 
or  has  gone  thi'ough  a  severe  operation,  nutrient  enemata  mil 
usually  be  needed.      On   the   morning   of   the  third  day  the 
patient  can  generally  take  tea  and  toast,  and  may  dine  off  a 
cup  of  beef -tea.     By  the  fourth  or  fifth,  boiled  sole  or  whiting 
may  be  given,  for,  although   nothing    should   be    hurried  on, 
it  cannot  be  denied  that  slops  may  disagree,  and  cause  flatulence 
or  nausea,  when  solids  agree  perfectly.     Many  patients  com- 
plain of  pain  along  the  jaws,  due  to  the  unaccustomed  want  of 
something  to  masticate,  if  kept  too  long  without   solid  food. 
After  taking  fish  for  dinner,  and  bread-and-butter  with  tea  for 
breakfast  and  supper  for  two  days,  a  wing  of  a  chicken  may  be 
tried,  and,  later  on,  a  mutton-chop  well  minced.       The  appetite 
may  fail  through  the  means  taken  to  make  the  bowels  act  for 
the  first  time,  and  then  meat  must  not  be  given  for  a  day  or 
two.     When  the  patient  loses  her  appetite  at  the  end  of  the 
fii'st  week,  before  any  aperient  or  enema  has  been  given,  with- 
out evidences  of  peritonitis  or  local  troubles  near  the  pedicle, 
nor  of  exhaustion,  it  will  be  necessary  to  administer  a  laxative, 
with  or  without  the  enema,  as  "^'ill  presently  be  directed.     The 
nm-se  must  be  allowed  to  exercise    judgment   Avith   regard   to 
diet    during   the   first   few   days.      Some    cases    can   swallow 
milk  with  impunity  six   or  twelve  hom's  after  operation,  but, 
as   a   rule,    the   nurse    must    be    slow   to    give    anything   by 
the  mouth  till  the  second  day.     Exclusive  milk-diet  promotes 
the  formation  of  troublesome   scybala.      The   surgeon   should 
always  prescribe  the  dinner  for  a  week  or  two  after  the  second 
day,  as  the  patient  otherwise  may  be  allowed  butcher's  meat 
too  freely,  and  restlessness,  abnormal  excretion  of  urates,  and 
other  troublesome  symptoms  may  follow.     The  above  general 
rules  must  be  observed,  but  it  is  clearly  impossible  to  lay  down 
an  unvarying  law  for  the  dietary  of  an  ovariotomy  patient. 
The  Administration  of  Opium. — Some  operators  give 


OPIUM BEEF-TEA   EIsEMATA.  245 

opium  as  a  matter  of  routine  ;  others  never  administer  the  drug 
excepting  to  ease  the  agonies  of  a  dying  patient.  From 
experience  in  the  wards  of  the  Samaritan  Hospital,  I  must 
express  myself  strongly  against  the  indiscriminate  or  routine 
administration  of  opium.  Sir  Spencer  Wells'  observations  on 
concentrated  urine  in  ovarian  cases  have  been  already  noted. 
Such  cases  I  have  ever  found  to  be  the  most  intolerant  of 
opium  after  operation.  Under  its  influence  the  urine  is 
scanty,  and  more  loaded  with  urates  than  before  ovariotomy, 
and  these  abnormal  constituents  appear  to  irritate  the  bladder, 
even  when  the  catheter  has  been  carefully  used  by  the  most 
experienced  nurse.  Still  more  unfavourably  does  opirun  act  in 
those  yet  more  serious  cases  where  the  urine  is  scanty,  slightly 
albuminous,  and  of  low  specific  gravity.  On  the  other  hand, 
when  the  patient  is  restless  from  individual  intolerance  of  the 
pain  generally  felt  in  the  iliac  region  for  the  first  few  days,  and 
when  all  unfavom^able  symptoms  are  absent,  twenty  minims 
of  the  tincture  of  opium,  administered  in  an  ounce  of  warm 
water  as  an  enema,  about  every  six  hours,  will  have  a  good 
effect  in  calming  her.  The  drug  should  be  discontinued  as 
soon  as  j^ossible.  Some  specialists  administer  the  opium  in 
the  beef-tea  enemata. 

Beef-tea  Enemata. — It  cannot  be  denied  that  nutrient 
injections  of  beef -tea  into  the  rectum  are  of  great  service  in 
the  earhest  stages  of  the  after-treatment  of  patients  who 
have  undergone  ovariotomy  or  any  other  form  of  abdominal 
section.  Whether  the  vomiting,  so  frequent  and  so  troublesome 
after  operation,  be  due  to  the  anaesthetic  or  to  shock,  or  to  the 
influence  of  the  ligature,  it  certainly  interferes  with  the  adminis- 
tration of  nourishment  in  the  ordinary  manner.  If  the  patient 
be  kept  without  any  food  for  twenty-four  or  forty-eight  hours, 
she  is  liable  to  become  restless,  and  may  suffer  fi'om  attacks 
of  faintness,  not  only  distressing  and  dangerous  to  herself, 
but  also  misleading  to  the  surgeon,  who  may  overlook  the 
true  cause  of  the  tendency  to  syncope,  and  suspect  some 
mischief  in  the  region  of  the  pedicle. 

The  surgeon  may  have  to  conduct  his  treatment  under  cir- 
cumstances where  good  beef-tea  cannot  be  procm-ed  with  any 
certainty  or  regularity.      Among  the  best  artificial  preparations 


246  OVARIOTOMY  :  AFTER-TREATMENT,  ETC. 

is  Jolinston's  peptonized  fluid  beef.  A  di-aehm  is  dissolved  in 
two  ounces  of  boiling  water,  and  an  oimee  of  cold  water  is 
afterwards  added.  "Wherever  there  is  a  cook  or  nui'se  who  can 
make  good  fresh  beef-tea,  that  preparation  is  the  best.  It 
must  be  prepared  mthout  salt. 

Some  robust  joung  patients  will  certainly  require  but  one  or 
two  nutrient  enemata  within  the  fii'st  twenty-fom-  hom"s,  and 
some  of  my  own  cases  have  fared  excellently  without  this 
method  of  nourishment.  After  moderately  prolonged  or  severe 
operations,  and,  I  believe,  even  after  simple  operations,  in 
middle-aged  or  elderly  women,  nutrient  enemata  should  always 
be  administered.  They  must  be  given  so  as  to  nomish,  without 
causing  distension  of  the  abdomen,  so  as  to  be  retained  with 
certainty,  and,  lastly,  so  as  to  be  absorbed  without  partially 
remaining  to  decompose  in  the  rectum.  The  injections  should 
be  given  about  once  every  foiu-  hom's.  If  the  patient  be 
very  weak,  the  interval  may  be  reduced  to  two  houi-s ;  if  she 
be  strong,  and  only  suffering  from  slight  shock,  it  may  be 
extended  to  six  hours.  The  first  enema  should  be  given  six 
hours  after  operation. 

Before  the  enema,  is  given,  a  short  O'Beirne's  tube,  or  the 
vaginal  pipe  of  an  ordinary  siphon  eneiaa  of  the  Higginson 
type,  must  be  passed  for  about  two  or  three  inches  into  the 
rectum,  and  left  there  for  a  few  minutes.  A  small  bowl  or 
soap-dish  must  be  placed  under  the  part  of  the  pipe  hanging 
out  of  the  rectimi ;  then  flatus  and  small  particles  of  isecal 
matter  can  escape  freely,  and  the  latter  are  received  in  the 
receptacle.  The  pipe  is  then  removed,  and  thi*ee  ounces  of  the 
enema  are  introduced.  The  enema  must  not  be  too  hot,  else  it 
will  not  be  retained  ;  if  just  wann  enough  to  be  fluid,  that  vnR 
be  sufficient.  When  the  patient  is  in  great  pain,  twenty  drops 
of  laudanum  may  be  added  to  the  enema,  and  this  may  be 
done  to  a  second  if  the  first,  not  containing  any  opiate,  has  been 
ill-retained.  The  enema  must  be  repeated  every  four  hoirrs, 
the  pipe  being  always  introduced  first.  When  the  patient  is 
very  weak,  enemata  will  be  rec[uired  at  intervals  of  three,  or 
only  two,  hom's. 

Mr.  Thornton  recommends  that  if  the  refuse  from  the  rectal 
feeding  be  offensive,   or   if   too   much   comes   away,  a  couple 


BEEF-TEA    ENEMATA BED-SORES THE    BOWELS.  247 

of  grains  of  quinine,  in  a  dessert-spoonful  or  table-spoonful  of 
port  wine,  must  be  added  to  each  injection.  Septic  miscliief 
may  manifestly  be  set  up  by  the  retention  of  putrid  enemata 
in  a  rectum  the  mucous  membrane  of  which  has  become  sore. 
The  operator  must  never  overlook  this  source  of  danger  from 
injections.  After  the  first  forty-eight  hours  they  may  be  dis- 
continued, especially  if  the  patient  can  take  nourishment  by 
the  mouth. 

The  c[uestion  of  opium  after  ovariotomy  has  been  already 
considered.  I  believe  that  the  drug  is  useful,  not  only  when 
the  patient  is  in  great  pain,  but  also  when  the  enemata  are 
not  well  retained  if  administered  without  it. 

Bed-sores. — As  the  patient  lies  on  her  back  for  a  week  or 
longer  after  ovariotomy,  it  stands  to  reason  that  care  must 
be  taken  to  avoid  bed-sores.  Careless  catheterism  and  soiling 
of  the  bed-clothes  during  voluntary  micturition,  rucking  up  of 
the  night-dress,  creasing  of  the  sheets,  and  escape  of  bread- 
crumbs, etc.,  under  the  patient's  body,  may  be  the  cause  of 
these  untoward  complications.  As  there  are  seldom  any  j)ara- 
lytic  conditions  in  patients  with  ovarian  disease,  and  as  no 
surgeon  undertakes  ovariotomy  without  either  employing  the 
best  nurse  he  can  find,  or  at  least  exercising  strict  personal 
supervision  during  the  after-treatment,  bed-sores  after  ovari- 
otomy, or  any  other  kind  of  abdominal  section,  are  rare. 

The  prophylaxis  of  bed-sores  is  well  known.  The  evils 
above  referred  to  must  be  avoided.  Careful  adjustment  of 
the  clothes  and  sheets  under  the  patient  is  ever  necessary, 
and  the  application  of  fuller's-earth  to  the  integuments  over 
the  sacrum  and  trochanters  will  prove  of  great  benefit  when- 
ever there  is  the  least  fear  of  any  trouble,  especially  in  heavj^ 
old,  or  feeble  subjects.  Boracic  lint  is  an  excellent  dressing 
for  a  bed-sore,  after  separation  of  the  slough,  and  iodoform 
should  be  blown  over  its  surface,  daily,  by  means  of  an 
insufilator  (see  page  138). 

Opening  the  Bowels. — I  have  carefully  observed  the 
after-treatment  of  several  hundred  patients  under  the  charge 
of  my  colleagues  and  myself.  I  find  that  it  is  a  very  good 
rule  to  take  steps  to  open  the  bowels  by  the  evening  of  the 
seventh  day.      Sometimes,  but  rarely,  they  act  spontaneously 


248  OVARIOTOMY  :  AFTER-TREATMENT,  ETC. 

mucli  earlier,  but  tliis  is  no  disadvantage,  excepting  that  it 
must  be  seen  that  the  nui'se  does  not  distui'b  the  patient  too 
much  in  adjusting  the  bed-pan.  Towards  the  eighth  daj'', 
however,  the  patient,  who  has  begun  to  eat  well,  is  apt  to 
feel  uncomfortable. 

Should  the  tongue  be  clean,  and  the  patient  free  from 
nausea,  loss  of  appetite,  high  pulse,  or  other  symptoms  of 
gastro-intestinal  irritation,  the  enema  will  be  the  best  means 
of  opening  the  bowels,  and  the  patient's  appetite  need  not  be 
spoilt  by  drugs.  The  surgeon,  unless  he  has  an  exjDerienced 
nurse  to  aid  him,  should  explore  the  rectum  for  scybala.  If 
such  be  found,  foiu'  ounces  of  warm  olive  oil  should  be  injected  ; 
if  there  be  no  scybala,  about  two  ounces  will  be  sufficient. 
Four  hours  later,  a  pint  and  a  half  of  soap-and- water  should 
be  injected.  Should  several  houi's  elapse,  and  the  enema  be 
retained,  it  is  a  good  plan  to  introduce  a  tube  to  the  extent 
of  about  fom-  inches,  supporting  the  outer  end  by  a  soap-dish 
containing  a  little  water.  If  the  tube  be  left  in  the  rectum 
for  about  ten  minutes,  a  quantity  of  flatus  will  often  pass, 
and  then  the  patient  will  experience  a  desire  to  defaecate, 
and  will  pass  a  free  motion.  If  this  means  fail,  a  pint  more 
of  the  enema  may  be  injected,  and  the  treatment  continued 
till  the  bowels  act.  Should  the  patient,  however,  complain  of 
nausea  and  lose  her  appetite  in  the  meanwhile,  a  pm^gative 
will  be  advisable.  As  a  rule,  the  enema  soon  acts.  It  may 
be  repeated  every  forty-eight  hours  till  the  bowels  are  opened 
mthout  its  assistance,  and  should  be  administered  in  the 
morning. 

In  ver}'-  bad  cases,  on  the  other  hand,  the  enema  keejDS  the 
lower  bowel  clear,  whilst  purgatives  upset  the  patient.  I  refer 
to  cases  where  large  malignant  tmnom-s  have  been  removed, 
or  multiple  adhesions  broken  down,  and  where,  at  the  same 
time,  the  bad  symptoms  do  not  point  in  the  dii-ection  of  simple 
gastro-intestinal  irritation. 

Pm-gatives  without  enemata  are  very  popular  with  patients 
and  nurses,  and  sometimes  prove  highly  efficient.  '  When 
scybala  lie  in  the  rectum,  the  enema  is,  so  far,  preferable, 
for  i^ills  and  powders  sometimes  cause  a  loose  motion  to 
pass  from  the  upper  part  of  the  intestinal  tract,  whilst  the 


OPENING    THE    BOWELS.  249 

scybala  are  not  expelled.  They  tend  to  become  particularly 
irritating  under  these  circumstances.  From  what  I  have 
observed,  however,  I  think  that  the  patient  is  always  the 
better  for  a  purgative  if  her  tongue  be  thickly  furred,  her 
skin  sallow,  and  her  appetite  bad,  after  having  been  good 
towards  the  end  of  the  first  week.  To  this  condition  may  be 
added  nausea,  borborygmi,  and  griping  pains,  with  little  or 
no  rise  of  pulse  or  temperature,  and  possibly  there  may  be 
slight  bilious  vomiting.  It  is  now  my  practice,  when  such  a 
combination  of  symptoms  occui',  however  mildly,  to  administer 
a  drachm  of  compound  liquorice  powder  at  the  same  time 
that  the  preliminary  olive  oil  enema  is  injected.  Should 
the  patient  be  subject  to  constipation,  I  prefer  two  and  a  half 
grains  of  colocynth  and  hyoscyamus  pill.  After  the  soap-and- 
water  enema  has  been  injected,  a  free  motion  will  generally 
pass,  and  the  lower  bowel  will  be  well  cleared  by  the  mechani- 
cal agency  of  the  injection,  whilst  the  drug  will  exercise  a 
beneficial  action  higher  up.  As  intestinal  trouble  of  the  kind 
above  described  is  very  frequent  in  middle-aged  women,  I 
generally,  in  their  ease,  combine  the  enema  and  the  purgative 
in  this  way.  The  same  powder  or  pill  may  be  given  as 
required,  should  there  be  similar  trouble  later  on.  The 
enema  will  not  then  be  needed,  unless  the  surgeon  should 
detect  symptoms  of  rectal  irritation  and  find  scybala. 

If  there  be  any  doubt  about  the  efiiciency  of  the  nurse 
the  enema  should  not  be  ordered,  even  under  circumstances 
described  above  as  particularly  demanding  it.  Ill-trained 
nurses  are  apt  either  to  allow  much  of  the  enema  to  be  spilt 
out  of  the  anus,  or  to  inject  with  too  great  force,  so  as  to 
injure  the  intestine  and  tear  down  vascular  adhesions  that 
are  not  causing  obstruction.  One  operator  tells  me  that  he 
has  seen  severe  symptoms  follow  clumsy  use  of  the  enema. 

With  regard  to  the  above  observations  on  purgation  after 
ovariotom}^  I  may  say  that  the  operators  with  whom  I  am 
personally  acquainted  differ  widely  in  their  practice,  and 
more  than  one  are  still  undecided,  notwithstanding  years  of 
experience,  as  to  the  relative  value  of  enemata  and  drugs. 

I  have  spoken  above  chiefly  of  cases  where  the  patient  is 
quite    well,    or   subject   to    intestinal    ii-ritation   with   no    evi- 


250  OVAKIOTOMY  :    AFTER-TREATME?»'T,    ETC. 

dence  of  peritonitis.  "WTien  the  latter  complication  exists  in 
a  mild  form,  it  is  better,  as  I  have  already  stated,  to  clear 
the  lower  bowel  with  enemata  than  to  begin  with  diTigs.  The 
cpiestion  of  purgatives  in  severe  peritonitis  is  very  much  dis- 
puted. During  that  affection  the  patient  takes  little  nourish- 
ment, and  therefore  cannot  need  frequent  pm-gation,  which 
must  mechanically  distm-b  the  seat  of  disease,  ^r.  Tait 
strongly  advocates  saline  pm'gatives,  and  claims  excellent 
results.  As  a  rule,  however,  surgeons  prefer  to  rely  on  opiates, 
and  leave  the  bowels  alone  for  a  few  days  in  these  grave 
circumstances.  To  begin  on  the  second  or  third  day  with 
pm'gatives,  when  no  bad  sjTnptoms  are  present,  seems  to  me 
a  great  mistake.  I  know  of  a  case  where  hysterectomy  was 
performed,  and  sulphate  of  magnesia  was  administered  twenty- 
foiu*  hours  later.  The  patient  was  immediatelj^  seized  with 
vomiting,  and  died  in  a  few  hom"s. 

The  Bladder  and  the  Catheter. — For  a  short  time 
after  the  operation  the  bladder  will  requii'e  to  be  emptied  by 
the  catheter,  but  it  is  ad^asable  that  the  use  of  that  instru- 
ment be  discontinued  as  soon  as  possible.  Hence,  the  surgeon 
must  study  each  case  intelligent!}^,  in  respect  of  the  condition 
of  the  bladder,  and  should  not  adhere  to  routine.  At  the  same 
time,  the  skill  of  the  nui'se  is  a  factor  always  to  be  taken  into 
consideration  (see  page  191). 

A  few  patients  seem  predisposed  to  a  loss  of  the  power  of 
voluntary  micturition  for  many  days  after  the  operation, 
independently  of  its  severity,  and  of  their  age,  health,  or 
strength.  Strange  to  say,  this  idios}Ticrasy  appears  also  to 
be  independent  of  vesical  initation,  which  may  be  absent,  or 
present  in  a  mild  or  severe  form,  whilst,  on  the  other  hand, 
other  subjects  pass  urine  voluntarily  in  a  day  or  two,  though 
troubled  with  severe  cystitis.  Nor  does  this  difficulty  in  niic- 
tmition  necessarily  depend  on  some  neurosis.  A  large  pro- 
portion of  patients  can  pass  their  urine  voluntarily  after  the 
fu'st  forty-eight  hoiu-s.  I  have  known  this  to  occur  after 
the  most  severe  operations,  where  adhesions  were  all  but 
universal,  or  where  malignant  gro^\i:hs  were  left  behind. 
Neither  paralysis  of  the  bladder,  nor  eniu-esis,  is  usual  after 
ovariotomy. 


THE  CATHETER REMOVAL  OF  THE  SUTURES.      251 

The  catheter  should  be  used  every  six  hoiu's  for  about  two 
days  and  two  nights.  The  surgeon  must  ascertain,  towards 
the  end  of  forty-eight  houi's  after  operation,  whether  the 
patient  can  or  cannot  micturate  without  difficulty  or  pain. 
When  she  can  do  so,  the  catheter  may  be  discontinued,  the 
surgeon  warning  the  nurse  to  disturb  the  patient  as  little  as 
possible  when  placing  or  removing  the  urinal.  How  often  the 
urine  is  passed  voluntarily  must  be  ascertained,  lest  retention 
should  come  on  and  be  overlooked  for  a  time. 

It  is  always  advisable  that  a  silver  catheter  be  employed,  as 
that  is  far  easier  to  keep  clean  than  a  gum-elastic  instrument. 
It  must  be  kej)t  in  a  1  in  20  solution  of  carbolic  acid,  and 
mucus  should  be  washed  off  the  end  and  the  perforations  on 
the  sides  immediately  after  use.  Whenever  a  new  nm-se  is 
employed,  the  surgeon  must  carefully  exercise  his  judgment, 
and  make  sure  that  catheterism  is  done  properly.  Some 
enthusiastic  young  nm-ses  tend  to  use  the  instrument  longer 
than  it  is  needed,  so  as  to  get  as  much  practice  as  possible. 
Yery  many  niu-ses  are  only  too  ready  to  dispense  with  it  as 
soon  as  they  think  convenient.  To  counteract  such  evils,  the 
surgeon  must  Cjuestion  both  nurse  and  patient  discreetly,  so 
as  to  make  sm-e  whether  the  latter  really  requires  the  catheter, 
or  can  pass  her  urine  without  its  aid.  Both  too  long  and 
too  short  a  term  of  catheterism  may  be  the  direct  or  indirect 
causes  of  cystitis — probably  the  most  frequent,  and  not  the 
least  troublesome,  complication  after  ovariotomy.  Of  that 
affection  more  will  be  said  presently  (see  page  256). 

Removal  of  the  Sutures. — The  wound  having  been 
examined  on  the  eighth  day,  the  sutm*es  are  now  removed. 
The  surgeon  must  remember  several  facts  in  regard  to  this 
question.  In  the  first  place,  as  far  as  mere  union  is  concerned, 
the  apposed  peritoneal  sm-faces  become  united  in  a  very  few 
hours,  and  the  integuments  in  two  or  three  days.  Then,  as 
long  as  the  patient  lies  on  her  back,  there  is  no  agency, 
excepting  great  accumulation  of  flatus,  which  is  likely  to  pull 
the  sides  of  the  wound  asunder.  I  have  repeatedly  watched  an 
abdominal  wound  when  a  patient  happened  to  cough  or  strain. 
The  recti  become  shorter  for  a  few  seconds  ;  the  integumental 
part  of  the  wound  seems  to  sink  between  those  muscles,  but. 


252  OVARIOTOMY  :    AFTER-TREATMEXT,    ETC. 

whatever  theorv  may  be  advanced  with  regard  to  the  mechanism 
of  the  abdominal  muscles  as  a  whole,  the  wound  is  certainly 
not  dragged  upon  during  these  efforts.  As  soon  as  the  patient 
lies  on  one  side,  or  sits  upright,  the  contents  of  the  abdomen 
cause  pressm-e  in  the  direction  of  the  wound,  and  the  pressure 
will  more  or  less  steadily  persist  during  the  maintenance  of 
either  of  those  positions.  From  the  above  observations  it 
follows  that  the  surgeon  need  not  fear  to  remove  the  sutures, 
if  necessary,  before  the  bowels  are  opened,  but  he  must  be 
particular  about  the  position  of  the  patient  after  they  are 
removed,  and  must  ascertain  personally  that  the  abdomen  is 
well  supported  by  bandages.  If,  in  a  case  that  has  progressed 
up  till  the  eighth  day,  he  leaves  everything  to  nurses  after  the 
removal  of  the  sutures,  it  is  very  possible  that  the  patient  may 
be  allowed  to  lie  on  one  side  when  the  abdominal  bandage  is 
loose  or  has  slipped  upwards  so  as  not  to  exercise  even  pressure. 
This  oversight  will  cause  traction  on  the  wound,  and  possibly 
a  hernial  protrusion  afterwards. 

Although  the  sutm-es  are  of  little  or  no  use  after  the  eighth 
day,  the  surgeon  may  prefer  not  to  remove  them  all  at  once, 
and  ^\nll  leave  half  for  a  day  or  two  later.  If,  however,  there 
be  redness  around  the  point  of  exit  of  any  one  suture,  that 
suture  must  be  removed  at  once.  It  should  be  cut  on  the 
health}^  side,  if  both  sides  be  not  involved,  so  that  the  part 
of  the  suture  which  has  been  lying  in  irritated  or  inflamed 
tissues  will  not  be  pidled  thi'ough  the  healthy  part  of  the 
track. 

The  wound  must  be  gently  washed  first,  and  then  the  nm-se 
or  assistant  supports  the  abdominal  walls  on  each  side  near  the 
wound.  The  surgeon  then  seizes  the  knot,  rather  than  one  of 
the  ends,  of  the  uppermost  or  lowermost  suture,  and  pulls  it 
forwards,  so  that  the  part  of  the  suture  behind  the  knot  is  to  a 
certain  extent  exposed.  One  side  of  that  part  of  the  suture  is 
now  cut  across,  and  then  the  entire  suture  is  pulled  out.  Care 
must  be  taken  not  to  cut  through  both  sides  of  the  suture,  else 
a  portion  A^-ill  be  left  in  the  track,  and  may  be  ver}^  diificidt 
to  remove.  This  warning  applies  to  the  removal  of  a  suture 
anywhere,  but,  o^sdng  to  the  position  of  the  surgeon  in  relation 
to  the  abdomen,  and  to  the  chance  that  the  patient  may  cough 


REMOA'AL    OF    SUTURES THE    CICATRIX.  253 

or  hiccoTigli  during  the  process,  the  accident  is  more  likely 
to  occur  in  an  abdominal  wound  than  in  wounds  made  in 
parts  which  the  surgeon  can  face  more  comfortably  and  fix 
with  greater  certainty. 

The  remaining  sutures  are  removed  in  the  same  manner. 
The  wound  should  again  be  washed,  care  being  especially  taken 
to  remove  minute  incrustations  of  di'ied  blood  sometimes  seen 
round  the  suture-holes.  As  a  rule,  it  is  best  to  remove  the 
sutures  under  spray,  especially  when  the  abdominal  walls  are 
thick  through  fat.  After  the  removal  of  the  sutures,  the  wound 
must  be  carefully  dressed  with  carbolic  gauze.  If  the  wound 
be  carelessly  dressed  after  the  sutures  have  been  taken  out, 
there  will  be  danger  of  irritating  particles  of  dust,  dirt,  and 
epidermic  scales  getting  into  some  of  the  suture  holes  and 
causing  a  small  abscess. 

Grreat  care  must  be  taken  to  ensure  the  removal  of  every 
suture.  Sutures  are  not  at  all  unfrequently  overlooked.  In 
the  first  place,  a  portion  may  be  left  in  through  the  misad- 
venture above  described.  Secondly,  the  ends  of  a  suture  may 
have  been  cut  too  short,  so  that  the  surgeon  takes  the  knot  for 
a  small  dried  clot  hard  to  wash  away,  and  leaves  it  for  another 
dressing,  and  then  forgets  all  about  it.  When  a  long  wound 
has  been  made,  and  a  bulky  tumour  removed,  the  wound 
shortens  and  puckers,  so  as  to  conceal  some  of  the  ends  of 
its  sutures.  Hence,  the  longer  the  wound,  the  more  careful 
must  be  the  scrutiny  when  it  is  dressed.  The  importance  of 
noting  the  number  of  sutures  in  the  case-book  is  self-evident. 

The  Cicatrix. — The  Abdominal  Belt. — The  wound 
having  been  dressed  with  the  greatest  care,  and  the  sutures 
duly  removed,  the  surgeon  must  never  forget  that  a  lono- 
cicatrix  remains,  and  that  it  may  stretch  and  form  a  hernial 
sac,  into  which  a  large  mass  of  intestine  and  omentum  may 
obtrude  itself,  to  the  great  annoyance  of  the  patient.  A 
distinguished  operator  once  observed,  in  speaking  to  some 
spectators  at  an  operation  which  he  had  just  concluded,  that 
owing  to  his  former  ignorance  of  the  proper  manner  of  closing 
the  abdominal  wound,  some  patients  on  whom  he  had  operated 
many  years  since  were  suffering  from  hernia  of  the  cicatrix 
and  they  had  informed  him  that  they  felt  more  inconvenience 


254 


OVARIOTOMY  :    AFTER-TREATMENT,    ETC. 


from  that  complication  tlian  they  ever  experienced  from  the 
tumonr  before  it  was  removed.  This  fact  suggests  more  than 
careful  application  of  the  sutures :  it  shows  the  importance  of 
protecting  the  cicatrix  long  after  convalescence. 

The  woodcut  (Fig.  110)  represents  part  of  the  integuments  of 


Fig.  110. — A  Hekmal  Pouch  developed  in  the  Cicatutx  of  the  Abdominal 

"WorXD    AFTER    OVAKIOTOMY,    AND    EXCISED    DURING    LiFE. 

It  is  seen  from  its  inner  aspect,  so  as  to  show  the  shallow  secondary  pouches 
in  the  peritoneum.  {Museum  R.C.S.,  No.  4,562.) 

the  abdomen  around  the  cicatrix  of  an  ovariotomy  incision,  as 
seen  from  the  inner  side.  They  have  become  distended  into  a 
pouch  by  the  gradual  yielding  of  the  cicatricial  tissue.  The 
peritoneal  lining  of  the  pouch  is  well  displayed.     This  pouch 


DISTENSION  OF  CICATRIX — GASTRO-INTESTINAL  DISTURBANCE.    255 

was  excised  by  Mr.  Thornton,  in  the  course  of  a  second 
ovariotomy.  The  first  operation  had  been  performed  by 
another  sm^geon  fifteen  years  earlier.  I  have  seen  more  than 
one  pouch  of  this  kind  removed,  and  with  unfailing  benefit  to 
the  patient.  I  have  also  seen  this  complication  in  cases  where 
there  was  no  second  ovarian  tumour,  and  it  always  appeared  as 
an  ugly  ventral  hernia,  not  very  dangerous,  since,  in  a  rupture 
of  this  kind,  the  neck  of  the  sac  is  extremely  wide,  but  in  every 
ease  very  troublesome,  so  as  almost  to  justify  excision  of  the 
redundant  integuments  and  cicatricial  tissue  as  an  operation 
by  itself.  After  the  use  of  the  clamp,  where  failui^e  of  union 
by  first  intention  was  common,  this  complication  was  more 
frequent  than  it  is  in  these  days  when  the  clamp  is  practi- 
cally discarded. 

Distension  of  the  cicatrix  occurs'  not  so  much  from  frequent 
coughing,  or  straining,  as  from  passive  pressure  from  within 
(see  page  251);  this  occurs  when  the  patient  sits  upright  too 
soon,  or  may  be  caused  simply  by  a  large  collection  of  flatus 
in  the  intestines.  "When  the  surgeon  is  dressing  the  wound 
during  the  convalescence  of  the  patient,  he  will  probably  have 
an  opportunity  of  seeing  this  pressure  in  active  progress.  If  the 
abdominal  walls  be  left  unsupported  for  a  minute,  a  few  more 
or  less  distended  coils  of  intestine  will  be  seen  behind  the  area 
of  the  cicatrix.  This  pneumatic  force  is,  be  it  observed,  in 
action  when  the  patient  lies  in  bed,  Hence,  she  must  be 
reminded  not  to  leave  off  the  binder  for  a  year,  or  longer. 
She  may  take  off  the  abdominal  belt  worn  in  the  daj^-time, 
but  she  must  not  leave  the  abdominal  walls  entirely  unsup- 
ported at  night.  In  the  day-time,  of  coui'se,  the  powerful 
support  of  the  belt  is  needed,  to  overcome  the  passive  force  of 
the  viscera  bearing  forwards  and  downwards  on  the  abdominal 
walls,  and  to  support  the  sides  so  as  to  prevent  undue  lateral 
action  by  means  of  the  obliques  and  transversales  muscles. 

Gastro-intestinal  Disturbance. — Some  patients  are  very 
sick  after  recovering  from  the  ansesthetic.  They  should  then 
be  allowed  to  suck  ice  and  to  take  an  occasional  teaspoonful 
of  barley-water.  Drugs  will  seldom  be  needed.  When  the 
retching  is  severe,  the  stomach  may  be  washed  out  with  a 
tumbler-full  of  warm  water.    This  will  cause  the  patient  to  bring 


256  OVARIOTOMY  :    AFTER-TREATMEXT,    ETC. 

up  much  frothy  mucus,  or  even  green  fluid  with  great  relief. 
The  straining  will  necessarily  be  much  less  than  before  the 
administration  of  the  water,  which,  indeed,  generally  causes 
that  symptom  to  disappear  altogether.  Diarrhoea  is  very  un- 
usual, and  when  it  occm-s  it  is  oftentimes  the  result  of  giving 
an  aperient  within  a  day  of  the  operation  (see  page  194).  The 
nurse  should  place  her  right  hand  firmly  but  gently  over  the 
patient's  abdomen  during  an  attack  of  vomiting.  An  action  of 
the  bowels  soon  after  ovariotomy  is  not  a  grave  accident,  pro- 
vided that  the  patient  be  disturbed  as  little  as  possible  during  the 
adjustment  of  the  bed-pan.  In  all  early  troubles  of  this  kind 
the  principle  is  to  keep  the  patient  without  food,  except  in  the 
form  of  beef-tea  enemata.  Twenty  minims  of  the  tincture  of 
opium  may  be  mixed  with  the  enema  and  given  every  six  hours 
when  there  is  a  tendency  to  dian?hoea.  For  simjDle  sickness  I 
do  not  consider  that  any  opiate  should  be  given. 

Flatulence  is  sometimes  very  troublesome  during  the  first 
few  days.  The  rectal  tube  should  always  be  employed  for  its 
rehef ;  but  when  there  is  marked  nausea  or  other  indication 
that  gas  has  collected  in  the  small  intestines  or  stomach,  half- 
drachm  doses  of  aromatic  spirits  of  ammonia  will  prove  highly 
beneficial. 

Towards  the  seventh  and  eighth  day,  most  patients  suffer  more 
or  less  from  the  effects  of  enforced  constipation.  The  appetite, 
which  had  improved,  becomes  bad  again,  fur  collects  on  the 
tongue,  and  flatulence  with  griping  pain  is  very  frequent. 
Sometimes  there  is  sickness,  but  very  often  nausea.  In  severe 
cases  of  this  kind,  perfectly  uncomplicated,  I  have  seen  the 
temperature  fall  to  97*5^.  Severe  pain,  yet  absence  of  abdominal 
tenderness  on  touch,  is  very  characteristic  of  this  condition, 
which  always  disappears  after  successful  purgation. 

Cystitis. — Inflammation  of  the  bladder  is  a  common  compli- 
cation after  ovariotomy.  The  patient  complains  of  hypogastric 
pains,  and  feels  a  cutting  sensation  dm-ing  micturition.  Some- 
times, however,  the  disease  is  so  mild  that  frequent  desire  to 
pass  water  is  the  sole  subjective  symptom.  In  one  case  of  a 
woman  aged  sixty-tliree,.  even  this  symptom  was  absent,  though 
the  urine  was  charged  with  mucus.  The  mine  deposits  rojiy 
mucus,  often  mixed  with  a  considerable  amount  of  phospliates. 


CYSTITIS.  257 

Tlie  surgeon  must  remember  that  pain  ckmng  mictmition  may 
be  due  to  a  vascular  urethral  growth. 

I  certainly  believe  that  the  presence  in  the  bladder  of 
concentrated  urine,  loaded  with  urates,  and  the  difficulty 
which  many  patients  experience  in  emptying  tlie  bladder 
thoroughly  into  a  slipper  or  bed-pan,  are  predisposing  causes 
of  cystitis  ;  but  the  immediate  cause  is  almost  invariably  bad 
catheterism.  New  or  inefficient  nurses  often  thrust  the  end  of 
the  catheter  into  the  vagina,  or  push  it  about  the  vestibule  fi-eely, 
before  they  succeed  in  passing  it  into  the  urethra.  In  this 
manner,  dust  and  dirt  from  the  pubic  hairs,  sebaceous  matter 
from  the  labia,  and  mucus  from  the  vagina  and  vestibular  glands, 
are  more  or  less  freely  introduced  into  the  bladder.  In  a  long 
series  of  operations,  cystitis  will  be  found  to  be  frequent  in 
inverse  proportion  to  the  skill  of  the  nurses  employed  to  conduct 
the  after-treatment. 

Fortunately,  the  inflammation  is  generally  mild,  disappearing 
when  its  cause  is  removed.  Barley-water  should  be  administered, 
and,  if  the  symptoms  be  severe,  buchu  will  be  advisable,  but  it 
is  always  best  to  avoid  drugs  during  the  first  week  after  ovari- 
otomy. Sometimes  the  disease  will  require  active  treatment. 
"When  m'ates  are  deposited  in  abundance,  and  cystitis  exists, 
ten  grains  of  citrate  of  potash  should  be  given  three  times 
a  day.  Free  deposit  of  phosphates  demands  the  administra- 
tion of  dilute  nitro-hydrochloric  acid. 

I  referred  above  to  the  difficulty  which  many  patients 
experience  in  emptying  the  bladder  sufficiently  into  a  bed-pan ; 
that  is,  in  the  recumbent  instead  of  the  usual  posture.  I  have 
kno-WTL  slight  cystitis  to  occur  in  invalids  suffering  fi'om  various 
maladies,  upon  whom  the  catheter  had  never  been  passed,  and 
in  these  cases  the  patients  complained  of  the  above-mentioned 
difficulty,  and  the  symptoms  of  vesical  irritation  disappeared 
when  they  became  strong  enough  to  get  out  of  bed  and  pass 
mine  in  the  usual  position.  In  a  few  ovariotomy  cases  imder 
my  observation,  I  have  reason  to  believe  that  cystitis  was 
caused  in  this  way.  In  such  cases,  again,  the  nm-se  may  be 
to  blame.  Feeling  herself  incompetent  to  pass  the  catheter, 
she  encourages  the  patient  to  micturate  voluntarily  too  soon 
after  the  operation. 


258  OVARIOTOMY  :    AFTER-TREATMEXT,    ETC. 

Rise  of  Temperature  after  Ovariotomy,  Hyper- 
pyrexia.— Whatever  may  be  said  to  the  contrary,  this  symptom 
always  will,  and  always  should,  give  cause  for  anxiety,  especially 
Avhen  the  temperature  exceeds  102°  ;  nevertheless,  it  must  not  be 
forgotten  that  it  may  be  due  to  a  definite  cause  other  than 
septic  changes,  readily  to  be  detected  by  the  surgeon.  Should 
he,  then,  find  that  a  patient  is  suffering  from  coryza,  bron- 
chitis, ao-ue,  or  some  other  self-evident  complication,  he  should 
not  assimie  that,  because  the  temperatiu-e  rises  to  102°  or  103" 
septicaemia  necessarily  lurks  behind  the  disease  which  evidently 
exists. 

Eecently,  there  has  been  a  tendency  to  place  great  stress  on 
the  pulse,  maldng  temperature  a  secondary  consideration.  This, 
however,  is  simply  the  outcome  of  a  long-recognized  clinical 
fact.  In  exhausting  fevers,  and  most  septic  conditions,  a  fall 
of  temperatui^e,  say  from  104°  to  102%  ^\dth  a  rise  of  pulse, 
frequently  precedes  death. 

I  have  seen  the  temperatm-e  rise  to  105-8'  on  the  fourth  da}^ 
in  a  patient  subject  to  ague ;  she  recovered.  Bronchitis,  and  even 
coryza,  may  send  the  temperature  up  to  over  102"^,  when  the 
special  spnptoms  of  those  complications  are  otherwise  trivial. 
The  approach  of  the  period,  and  metrostaxis  caused  by  the 
inclusion  of  uterine  tissue  in  the  ligatm-e  of  the  pedicle,  are  both 
accompanied  by  rise  of  temperatm^e.  This  symptom  may,  of 
com'se,  arise  from  comparatively  trifling  causes  in  the  weak 
or  aged. 

Treatment  of  High  Temperatures. — This  must  always 
mainly  depend  upon  the  source  of  the  rise  of  temperature.  Whilst 
the  sldn  is  stiU.  dry  for  the  first  twelve  hours  after  operation,  a 
considerable  rise  of  temperature  is  seldom  of  serious  import. 
AVhen,  however,  the  temperature  rises  to  over  102",  with  con- 
comitant rise  of  pulse,  it  will  be  necessary  to  take  to  measm-es 
having  for  their  direct  aim  the  reduction  of  temperature. 
Thornton's  ice-cap,  .abeady  described  (page  133),  is  excellent 
for  this  purpose  ;  and  Leiter's  temperatm-e  regulator  (page  135) 
also  answers  very  well — it  is  employed  in  Dr.  Bantock's  wards 
vdih  excellent  results.  The  cap  must  not  be  put  on  till  the  sldn 
has  acted,  and  must  not  be  taken  on  and  off,  but  kept  on  till  the 
temperatm-e  has  steadily  gone  down,  remaining  below  100'. 


HIGH    TEMPERATURES SEPTIC.llMIA.  259 

Wet-packing  is  seldom  needed,  but  in  some  cases,  when  the 
temperature  keeps  very  high  notwithstanding  the  ice-cap,  it 
may  be  necessary.  The  arms  should  first  be  packed  in  wet 
towels,  kept  moist  by  ice-cold  water  squeezed  upon  them  from 
a  sponge.  The  lower  extremities  and  even  the  chest  may 
require  packing,  if  the  application  of  cold  to  the  arms  fail  to 
reduce  the  temperature.  The  jDulse  and  temperature  must  be 
frequently  taken,  as  great  depression  may  suddenly  occur  during 
wet-packing. 

Septicaemia,  Pyaemia,  and  Peritonitis. — These  deadly 
septic  complications,  which  may  follow  any  operation,  are  fully 
described  in  works  on  surgery  and  pathology,  so  that  it  is  not 
necessary  for  me  to  write  at  length  on  septicaemia  and  the  subtle 
questions  associated  with  that  condition.  One  of  these  cj^uestions 
is,  the  relation  of  septicsemia  to  peritonitis.  All  that  need  here 
be  said  is  that,  as  regards  the  results  of  ovariotomy,  this  relation 
appears  to  be  very  close.  Every  surgeon  knows  how  acute  peri- 
tonitis with  marked  symptoms  often  passes  into  a  condition  indi- 
cating septic  infection,  and  how,  on  the  other  hand,  evidences 
of  inflammation  of  the  peritoneum  are  found  after  death  from 
septicsemia,  where  the  most  prominent  symptoms  of  peritonitis 
were  absent.  The  nature  of  septic  pneumonia  must  not  be 
overlooked,  in  relation  to  septicsemia  after  ovariotomy,  and 
the  symptoms  of  gastro-intestinal  irritation  depend  upon 
conditions  well  known  to  the  pathologist.  The  proximate  cause 
of  septicsemia  after  ovariotomy  is,  in  the  great  majority  of  cases, 
absorption  of  septic  fluid  by  the  peritoneum.  That  it  may 
sometimes  arise  from  damage  to  vessels  in  the  pedicle,  inflicted 
by  the  ligature  or  clamp,  there  can  be,  I  believe,  no  doubt. 
Improved  methods  of  securing  the  pedicle  have,  however,  made 
septicsemia  from  this  cause  very  rare. 

Septicsemia  generally  sets  in  between  the  second  and  the 
seventh  day.  It  must  be  diagnosed  through  the  combination  of 
symptoms  by  which  it  is  manifested  clinically — a  combination 
only  too  well  known.  Yomiting,  after  the  subsidence  of  the 
more  or  less  distinct  nausea  caused,  in  some  subjects,  by  the 
ansesthetic,  is  a  serious  symptom.  Steady  rise  of  temperature 
with  simultaneous  rise  of  the  pulse  constitutes  a  particularly 
grave  and  characteristic  symptom.     A  fall  of  high  temperatm-e 


260  OVARIOTOMY  :    AFTEK'TREATMENT,    ETC. 

to  the  extent  of  one  degree  or  more,  with  increase  of  frequency 
of  the  abreadj^  high  pulse,  or  mth  a  distinct  decrease  in  the  force 
of  the  pulse-beats  without  increase  in  their  frequency,  is  yet 
more  grave.     The  respirations  are  always  increased. 

Persistence  of  vomiting,  especially  when  the  ejecta  become 
no  longer  white  and  frothy,  but  green  or  dark,  is  highly 
unfavourable,  as  is  tympanites.  The  surgeon  will  have  to 
consider  in  special  cases  whether  flatulent  distension  of  the 
intestines  be  due  to  the  effect  of  septic  infection  on  the  innerv- 
ation of  the  muscular  coat  of  the  bowel,  or  to  some  mechanical 
obstruction.  It  is  a  bad  sign  when  flatus  does  not  pass  through 
the  tube.  The  abdominal  walls  are  generally  tender  to  touch, 
though  seldom  to  a  marked  degree. 

The  facial  aspect  of  the  patient  seldom  fails  to  attract  the 
surgeon's  attention.  The  complexion  becomes  muddy,  the 
expression  nearly  always  didl.  A  dark  red  flush  on  the  cheek 
is  a  Yerj  bad  sign.  The  mental  condition  is  depressed  and 
pessimistic  at  first,  but  soon  becomes  apathetic. 

The  condition  of  the  tongue  and  skin  varies  considerably, 
and  is  therefore,  in  itself,  a  less  reliable  symptom  than  even 
the  change  of  facial  aspect.  As  a  rule,  the  tongue  grows 
rough,  red,  and  dry,  and  the  skin  remains  dry  till  near  death ; 
but  the  tongue  may  remain  moist  and  the  skin  act  profusely 
throughout. 

True  pyaemia  is  rare  after  ovariotomy.  The  suppurative 
inflammation  of  the  parotid  gland,  to  which  I  will  presently 
allude,  appears  to  represent  this  condition ;  it  certainly  arises 
about  the  period  that  pysemia  might  be  expected. 

As  for  prognosis,  the  more  the  above  group  of  symptoms 
prevail  and  continue,  the  graver  will  it  be.  The  treatment  of 
septicaemia  is,  speaking  generally,  essentially  prophylactic. 
Cleansing  the  peritoneum,  securing  the  pedicle  properly, 
checking  all  sources  of  hosmorrhage,  and  making  use  of  the 
drainage-tube  when  necessary,  are  the  most  j)otent  causes  of 
the  decline  of  septicemia  after  operation. 

Judging  from  what  I  have  seen,  sej)ticcBmia  when  it  has 
once  set  in  is  very  unamenable  to  any  active  kind  of  treatment. 
The  re-opening  of  the  abdominal  wound  and  the  introduction 
of  a  drainage-tube  into  Douglas's  pouch  are  sometimes  almost 


SEPTICEMIA,    PYEMIA,    A^'D    PERITONITIS.  261 

airily  recommended  as  duties,  easy  to  perform.  The  fact  is, 
that  there  is  a  great  difference  between  introducing  a  tube 
during  and  after  operation.  In  the  latter  case  the  patient  is 
in  a  highly  unfavourable  condition  to  bear  interference,  and  it 
is  very  difficult  to  get  the  end  of  the  tube  well  to  the  bottom 
of  Douglas's  pouch ;  the  intestines  are  generally  distended 
with  flatus,  and  glued  more  or  less  together  by  lymph;  their 
coats  may  even  be  dangerously  softened  by  inflammatory 
changes ;  above  all,  it  is  impossible  to  make  sui'e  that  drainage 
•  can  be  effected  at  all.  In  several  cases  which  I  have  observed, 
this  introduction  of  a  tube  seemed  only  to  aggravate  the 
patient's  condition.  When  some  objective  local  symptom  is 
marked,  such  as  hardness  or  fluctuation  in  the  pelvis,  or  in 
the  abdominal  walls  around  the  wound,  the  case  is  different ; 
abscess  is  probably  forming,  and  will  require  suitable  treatment. 
Such  cases  are  relatively  less  serious  than  those  where  only 
general  symptoms  of  septicaemia  jDrevail. 

The  vomiting  must  be  relieved.  If  the  vomit  be  bilious 
or  dark,  the  stomach  should  be  washed  out  with  warm  water 
by  means  of  the  stomach-pump  or  through  a  long  red-rubber 
rectum-tube  every  six  or  twelve  hours  till  the  vomiting  and 
accumulation  of  fluid  cease.  Shortly  after  each  washing,  some 
liquid  nom-ishment  may  be  given,  with  stimulants  if  necessary. 
The  temperatm-e,  if  over  102°,  should  always  be  reduced  by 
means  of  the  ice-cap  or  Leiter's  temperature  regulator,  applied 
in  the  manner  already  described.  After  the  washing  out  of 
the  stomach  and  reduction  of  the  temperature,  a  considerable 
number  of  cases  of  septicaemia  get  better.  The  poison  elimi- 
nated by  the  gastric  mucous  membrane,  which  the  patient  is 
too  weak  to  throw  up  by  herself,  is  removed  so  that  it 
cannot  be  re-absorbed,  and  tissue-waste  is  checked.  After  this 
treatment,  the  prognosis  will  be  good  if  the  temperatm-e  and 
pulse  both  fall  distinctly  and  steadily.  The  patient's  aspect 
improves,  and  flatus  passes  freely  through  the  rectum-tube. 

Drugs  are,  I  beheve,  of  little  use  in  these  cases ;  aromatic 
spirits  of  ammonia  will,  however,  greatly  relieve  the  flatulent 
distension  of  the  stomach.  Beef-tea  enemata  must  be  adminis- 
tered independently  of  what  is  introduced  into  the  stomach  after 
it  is  washed  out. 


262  o^"ARIOTOMY  :  after-treatment,  etc. 

Internal  Haemorrhage    after    Operation :   Slipping 
and   Splitting  of  the  Pedicle. — The   meclianics  of  the 

hgnture  and  the  pedicle  are  differently  understood  by  different 
authorities.  Some  write  as  though,  when  haemorrhage  occui's 
from  the  stump  of  the  pedicle,  the  ligature  becomes  loosened 
by  pressure  of  the  tissues  on  its  knot,  and  slips  from  the  pedicle. 
Others  appear  to  believe  that  it  is  the  pedicle  that  shps  from 
beneath  the  loop.  Of  course  a  badly -tied  knot  may  yield  to 
pressm-e  from  within  the  loop.  On  the  other  hand,  the  stump 
of  the  pedicle  ma}',  in  certain  cases,  be  exposed  to  great  traction,  " 
especially  at  the  outer  border. 

The  most  experienced  operators  occasionally  lose  cases  fi'om  this 
accident.  I  haye  already  spoken  of  the  correct  way  of  seeming 
the  pedicle,  and  the  precautions  necessary  to  observe  during  the 
process.  It  is  particularly  important  that  the  assistant  shoidd  not 
drag  on  the  pedicle,  but  should,  on  the  contrary,  relax  it  as  the 
operator  tightens  the  knot  of  the  ligature  (page  221).  When  the 
pedicle  slips,  symptoms  of  internal  haemorrhage,  presently  to  be 
described,  will  be  almost  certain  to  appear,  and  the  operator 
will  be  compelled  to  reopen  the  abdominal  wound  and  discover 
the  som'ce  of  htemorrhage.  The  bleeding  pedicle  must  be 
immediately'  seized  with  the  fingers  and  compressed.  Then  it 
is  best  to  secure  the  pedicle  temporarily  with  a  large  pressure- 
forceps,  transfixing  beneath  its  blades,  and  tying  the  ligature  as 
before.  If  this  instrument  be  not  at  hand,  the  pedicle  may 
be  temporarily  tied  with  stout  silk  encircling  it  with  a  single 
loop  ;  then  the  transfixion  may  be  effected  mthout  fm-ther 
risk. 

Accidents  of  the  kind  just  described  are  rare  in  the  present 
day.  The  systems  of  tying  the  loops  are  now  well  understood. 
The  practice  of  tying  the  ovarian  vessels  in  the  outer  border  -of 
the  pedicle  separately,  whenever  that  border  appears  to  be 
tense  (see  page  219),  has  probably  saved  a  large  number  of 
Kves.  This  practice  protects  the  pedicle  fi'om  a  heavy  drag  on. 
its  outer  border.  The  ovarian  artery  alone  is  not  likely  to  slip 
even  from  under  a  ligature  applied  to  the  entire  pedicle  without 
the  extra  thread  on  the  outer  border ;  but  if  that  border  itself 
should  slip,  the  artery  mil  be  set  free  and  will  bleed  freely. 

Hsemorrhage  may  also  follow  sphtting  of  the  pedicle.     This 


SLIPPING    AND    SPLITTING    OF    THE    PEDICLE.  26-3 

accident  is  generally  caused  by  neglecting  to  cross  the  threads, 
so  that  the  two  halves  of  the  pedicle  are  pulled  asunder  as  each 
loop  is  being  tied  (Fig.  92,  page  187).  A  similar  mechanism 
may  produce  the  same  disastrous  result  when  the  sui-geon 
attempts  to  tie  the  ligatures  after  some  principle  which  he  does 
not  thoroughly  comprehend.  The  pedicle  must  be  transfixed 
and  tied  below  the  split  in  its  substance,  whetlier  the  accident 
be  discovered  before  or  after  the  close  of  the  operation. 

The  transfixion  of  a  vessel  involves,  I  believe,  other  dangers 
rather  than  haemorrhage. 

When  the  pedicle  has  been  split,  symptoms  of  internal 
haemorrhage  usually  appear  within  twelve  houi^s  after  operation, 
and  probably  come  on  with  less  rapidity  than  in  cases  of  slipping 
of  the  pedicle.  The  patient  becomes  faint  and  ansemic  with 
the  characteristic  pulse.  In  one  case,  at  least,  within  my  know- 
ledge, there  was  dulness  in  the  hypogastrium, .  caused,  as  the 
opening  of  the  abdomen  proved,  by  the  effused  blood.  The 
duty  of  the  surgeon  is  evident.  The  abdominal  aorta  should  be 
compressed  whilst  the  preparations  for  opening  the  abdomen 
are  being  made.  Directly  the  peritoneal  cavity  is  laid  open, 
the  operator  should,  as  I  have  already  observed,  make  at  once 
for  the  pedicle,  and  secure  it,  at  least  temporarily,  before  turning 
out  clots.  If  the  pedicle  be  bmued  in  coagula,  he  should  pass 
his  fingers  over  the  fundus  of  the  uterus,  and,  so  guided,  should 
grasp  with  them  the  remains  of  the  broad  ligament  on  the 
affected  side.  This  will  check  the  haemorrhage  whilst  the  clots 
are  being  cleared  off  the  pedicle. 

After  the  first  few  clays,  these  accidents  rarely,  if  ever,  occm', 
the  pedicle  shrinking  rapidly,  and  its  vessels  becoming  occluded. 
The  pedicle  certainly  manages  to  free  itself  from  its  ligatures 
not  very  long  after  operation,  without  any  consequent  haemor- 
rhage in  some  cases.  That  which  results  in  dangerous  haemor- 
rhage, when  it  occurs  within  forty-eight  hom'S  of  operation, 
.probably  causes,  when  it  takes  place  at  a  later  date,  morbid 
changes  of  another  kind. 

Haemorrhage  from  adhesions  may  cause  similar  symptoms, 
and  the  treatment  will  be  the  same.  The  surgeon  must  care- 
fully search  the  peritoneum  and  viscera  till  he  can  find  the 
bleeding  point  and  secure  it  by  ligature. 


264  OVARIOTOMY  :  AFTER-TREATMENT,  ETC. 

Intestinal  Obstruction. — This  may  occur  early  or  late 
after  operation,  from  the  adhesion  of  a  raw  surface  on  the  serous 
coat  of  the  intestine  (itself  representing  an  adhesion  broken 
down  during  the  operation)  to  some  neighbouring  structure,  so 
as  to  bend  or  drag  the  gut  sufficiently  to  obstruct  its  channel. 
The  neighbouring  structure  may  be  the  stump  of  the  pedicle. 
The  obstruction  may  cause  fatal  collapse,  or,  as  in  one  case 
which  I  examined  after  death,  perforation  of  the  intestine. 
The  latter  termination  is  generally  observed  when  the  compli- 
catian  comes  on  late.  There  are  several  other  ways  in  which 
obstruction  may  occur,  besides  that  just  named,  which  is  probably 
the  most  frequent.  The  omentum  may  adhere  to  the  ileum  so 
as  to  form  a  tight  band,  pressing  possibly  on  some  other  coil  of 
intestine  than  that  to  which  it  is  connected,  so  that  the  former 
becomes  obstructed.  A  piece  of  intestine  may  be  included  in 
one  of  the  sutures  applied  to  the  abdominal  wound,  through  the 
operator  neglecting  to  guard  the  contents  of  the  abdomen  with 
a  flat  sponge.  I  have  known  this  accident  to  occur  at  a  large 
general  hospital.  Shively  has  described  a  case  {New  York 
Jledkal  Journal,  vol.  si.,  1884,  page  292)  where  fatal  occlusion 
occurred  six  years  after  ovariotomy,  through  adhesion  of  a 
portion  of  the  ileum  to  the  lower  part  of  the  abdominal  cicatrix. 
A  loop  of  small  intestine  was  found  twisted  twice  around  the 
ileum,  between  the  adhesion  and  the  caecum. 

The  symptoms  will  be  the  same  as  when  intestinal  obstruction 
occurs  from  other  causes.  Abdominal  pain,  constant  vomiting, 
and  tympanitic  distension,  without  a  marked  rise  of  tempera- 
ture, will  be  almost  pathognomonic.  Unfortunately,  when  the 
complication  follows  within  the  first  week  or  two  after  opera- 
tion, the  symptoms  are  often  masked  by  other  conditions, 
especially  septicaemia  and  peritonitis. 

The  prophylactic  treatment  of  obstruction  will  chiefly  de^Dend 
upon  minute  attention  to  certain  precautions  abeady  noted. 
Ragged  pieces  of  omentum  should  be  cut  off,  and  the  distal 
part  of  the  stump  of  the  pedicle  must  not  be  cut  too  long  ; 
when  the  tumour  is  cut  away,  it  must  also  be  cut  even,  so  as  to 
leave  no  tags.  When  properly  cut,  the  free  edges  generally 
curl  in  towards  each  other  so  as  to  leave  no  raw  surface  which 
might  adhere  to  intestine.     The  state  of  the  gastro-intestinal 


FtECAL    fistula — FOREIGN    BODIES    IM    ABDOMINAL    CAAITY.    265 

tract  previous  to  a  contemplated  ovariotomy  skoiilcl  be  carefully 
ascertained. 

When  symptoms  of  obstruction  slowly  come  on  shortly  after 
operation,  relief  is  sometimes  afforded  by  a  mixture  of  ten 
minims  of  liquor  morpliinse  hydrochloratis  and  two  minims  of 
liquor  atropiee  in  a  teaspoonfid  of  water,  administered  every 
three  or  four  hom^s  till  the  distension  is  relieved,  as  Mr.  Thornton 
recommends.  This,  or  any  similar  mixture,  however,  is  probably 
of  real  benefit  in  those  cases,  but  in  those  cases  only,  where  the 
gut  is  paralysed  as  a  result  of  septic  peritonitis. 

In  cases  where  the  symptoms  of  mechanical  obstruction  have 
been  marked,  especially  when  they  have  occurred  later  than  the 
first  or  second  week,  and  independently  of  general  peritonitis, 
the  abdominal  wound  has  been  reopened  and  the  obstruction 
removed. 

Faecal  Fistula. — Sir  Spencer  Wells  describes  some  in- 
teresting cases  of  this  complication,  now  all  but  unknown  after 
ovariotomy.  In  Dr.  Lyon's  case,  performed  in  1866,  and 
quoted  by  Wells,*  there  were  pin-hole  perforations  in  the 
intestine,  exposed  through  opening  of  the  lower  part  of  the 
abdominal  wound  after  an  attack  of  vomiting.  Dr.  Keith  in- 
forms me  that  the  perforations  were  believed  to  have  been  made 
by  wounds  from  the  needles  used  in  applying  sutures  to  the 
abdominal  incision — an  accident  which  may  also  cause,  as  I  have 
stated,  obstruction.  When  some  of  the  sutures  were  removed, 
fseces  poured  out  from  holes  on  the  surface  of  the  intestine. 
In  January,  1880,  the  patient  was  alive  and  well,  but  a  ftiecal 
fistula  remained  at  the  lower  angle  of  the  abdominal  cicatrix. 

The  surgeon  may  profitably  remember  the  above  facts  con- 
cerning obstruction  and  fistula  when  called  in  to  a  case  of 
abdominal  trouble  of  any  kind  in  a  patient  who  has  an  ovari- 
otomy cicatrix.  After  recovery  from  ovariotomy,  the  patient 
should  be  warned  that  it  will  be  best  for  her  to  consult  a 
practitioner  whenever  constipation  or  other  abdominal  symp- 
toms appear,  not  forgetting  to  inform  him  that  she  has 
undergone  the  operation. 

Foreign  Bodies  left  in  the  Abdominal  Cavity. — I 
have  already  referred  to  the  dangers  of  leaving  sponges,  forceps, 

*  Diseases  of  the  Ovaries,  1S72,  p.  397. 


266  OVARIOTOMY  :    AFTER-TREATMENT,    ETC. 

etc.,  "behind  in  the  peritoneal  caxdt}'-,  and  noted  the  precautions 
to  be  observed  by  the  operator.  Intense  pain  and  acute  perito- 
nitis, commencing  within  the  first  two  days  after  ojoeration,  are 
always  suspicious  symptoms.  Nearly  all  the  cases  where 
foreign  bodies  have  been  left  in  the  abdomen  die  if  those  bodies 
be  not  removed.*  In  a  case  recorded  by  Dr.  Wilson,  of 
Baltimore,  a  sponge  was  removed  several  months  after  the 
operation,  from  an  abscess  in  the  abdominal  walls.  Olshausen 
relates  a  case  where  a  pressure-forceps  was  passed  by  the 
rectum  nine  months  after  ovariotomy.  In  a  case  of  Dr. 
Nussbaum,  of  Munich,  a  drainage-tube  remained  for  two 
months  in  the  patient's  body,  when  a  part  of  the  wound  opened 
after  a  dance,  and  the  tube  was  at  once  pulled  out  by  the  patient 
herself,  who  suffered  no  further  inconvenience. 

When  a  sponge  or  forceps  is  missing,  the  wound  must  be 
carefully  reopened.  It  is  useless  to  search  for  the  foreign  body 
by  external  manipulations.  I  have  kno^Ti  a  life  saved  in  one 
ease  after  the  forceps  had  lain  in  the  abdomen  nearly  twenty- 
fom-  hom's.  The  patient  must  never  be  allowed  to  run  the 
risk  of  almost  certain  and  speedy  death  on  the  chance  that  the 
foreign  body  may  be  discharged,  probably  after  great  impair- 
ment of  health,  thi-ough  the  abdominal  walls,  vagina  or  rectum. 

Morbid  Changes  in  the  Pedicle. — These  are  very  rare 
in  this  country  and  in  America  at  the  present  day.  In  a  case 
under  Dr.  Hegar,  the  distal  end  of  the  stump  was  passed  at 
stoo]  on  the  sixteenth  day.  When  the  pedicle  suppurates,  the 
ligatm'e  maj-  find  its  way  into  the  bladder  and  form  the  nucleus 
of  a  calculus,  or  it  may  be  discharged,  thi'ough  an  abscess,  out 
of  the  abdominal  wound  or  into  the  intestine. 

Abscess. — This  complication  is  also  very  rare  in  the  practice 
of  British  and  American  operators.  The  abscess  may  be  due  to 
morbid  changes  in  the  pedicle,  just  described,  or  to  irritation  of 
the  track  of  a  sutm-e  in  the  abdominal  wound.  It  must  be 
treated  on  general  sui^gical  j)rinciples.  Suture-track  abscesses 
may  cause  much  suffering,  but  they  rapidly  heal  when  opened. 

Thrombosis,  Phlegmasia,  Parotitis. — A  slight  swelling 
of  the  lower  extremity,  on  the  side  corresponding  to  the  ovarian 

*  The  accident  nui.st  liave  been  occasionally  overlooked  in  fatal  cases,  where 
no  necropsy  was  allowed. 


THROMBOSIS,    PHLEGMASIA,    PAROTITIS EMBOLISM.  267 

tumour  whicli  lias  been  removed,  is  occasionally  observed  dining 
convalescence,  especially  in  simple  cases  where  a  very  large 
tumour  has  been  taken  away,  and  the  patient,  feeling  remark- 
ably well  by  the  end  of  the  first  fortnight,  attempts  to  walk  or 
stand  too  soon.  In  many  of  such  cases  a  previous  history  of 
swelling  of  the  limb  can  be  traced.  In  the  mildest  and  most 
frequent  form  of  this  complication,  the  patient  complains  that 
one  leg  seems  bigger  than  the  other.  On  examination,  the 
integuments  over  the  tibia  are  found  to  be  oedematous,  but  no 
tender,  cord-like  veins  can  be  detected.  Sometimes  the  swell- 
ing is  marked  and  extends  to  the  thigh,  whilst  a  plugged  vein 
can  be  discovered,  and  all  the  symptoms  of  phlegmasia  may  be 
present,  with  much  constitutional  disturbance. 

When  any  sign  of  thrombosis  occurs,  the  patient  must  be 
kept  in  the  recumbent  position,  and  the  oedematous  limb  must  be 
covered  with  a  layer  of  wool  and  lightly  bandaged.  Iron  should 
be  administered,  and  attention  must  be  paid  to  the  bowels. 
After  the  subsidence  of  the  oedema,  she  must  not  be  permitted 
to  place  her  foot  on  the  ground  ;  the  limb  must  be  supported 
as  she  is  shifted  from  the  bed  to  the  couch  or  sofa.  In  fact, 
this  complication  demands  careful  treatment,  and  is  in  any  case 
a  cause  for  anxiety.  A  more  serious  set  of  symptoms,  where 
inflammatory  changes  suddenly  appear  in  the  parotid  region, 
occasionally  occurs  after  ovariotomy.  This  parotitis  is  some- 
times of  a  septic  type,  when  suppuration  or  even  periostitis 
of  the  inferior  maxilla,  and  yet  wider  spread  mischief,  may 
follow.  In  other  cases  it  is  very  mild ;  its  precise  significance 
is  then  somewhat  obscm^e.* 

Pulmonary  Embolism. — This  deadly  complication  is  not 
unknown  after  ovariotomy.  In  one  case,  in  the  practice  of  a 
colleague,  the  patient  was  twenty-three  years  old ;  both  ovaries, 
subject  to  cystic  disease,  were  removed,  and  the  patient 
appeared  to  be  getting  well  very  rapidly,  Avhen  she  died  sud- 
denly on  the  eleventh  day  while  talking  to  her  nurse.     There 

*  See  Goodell,  "  Inflainmatiou  of  the  Parotid  Glands -follo^viiig  Operations  on 
the  Female  Genital  Organs"  {Transactions  of  the  American  Gyncccological  Society, 
vol.  X.,  1885).  An  exhaustive  paper  on  "  Parotitis  after  Injury  or  Disease  of  the 
Abdomen  or  PeMs"  was  read  before  the  iledical  Society  of  London  in  February, 
1887,  by  Mr.  Stephen  Paget  (see  British  Medical  Journal,  vol.  i.  1887,  p.  613). 


268  OVARIOTOMY  :    AFTER-TREATMENT,    ETC. 

■was  no  necropsy  in  this  case  ;  still  tlie  evidence  was  in  favoiir 
of  pulmonary  embolism. 

The  possibility  of  this  accident  should  be  borne  in  mind, 
especially,  as  the  case  just  noted  may  suggest,  in  reference 
to  strict  caution  with  regard  to  young  and  active  patients  who 
recover  rapidly  fi'om  the  operation.  Notwithstanding  the 
greatest  powers  of  enforcing  discipline,  and  the  highest  gifts 
of  inspiring  confidence,  nurses  generally  find  patients  of  this 
class  difficult  to  manage.  Yet,  should  a  fatal  accident  occiu-, 
the  sui'geon  will  always  feel  that  he  is  to  a  certain  extent 
responsible. 

Syncope  from  Anaemia  of  the  Brain. — Palpitations. 
— Olshausen  lays  some  stress  on  this  comphcation  and  its 
physiological  explanation.  Syncope  certainly  occurs,  not  un- 
frequently,  after  the  removal  of  a  very  large  tumour,  and  it 
has  been  attributed  to  anaemia  of  the  brain.  Severe  attacks  of 
palpitation  are  not  rare ;  they  come  on  generally  at  night,  and 
seem  partly  due  to  the  removal  of  the  large  circulating  area 
included  in  the  vessels  of  the  tumour,  but  partly,  if  not  entirely 
in  some  cases,  to  prolonged  rest  in  the  supine  position  which 
is  enforced  on  the  patient.  In  fact,  each  attack  is  simjply 
nightmare  from  sleeping  on  the  back.  It  may  give  great 
alarm  to  an  inexperienced  nurse.  In  one  of  my  own  patients 
where  this  symptom  occurred,  I  found  out  that  she  had  been 
subject  to  palpitations  after  every  labour,  the  first  occm'ring 
twenty-seven  years  before  the  operation.  Half  a  di-achm  of 
aromatic  spirits  of  ammonia,  in  half  a  wine-glassful  of  water, 
will  give  great  relief,  and  the  patient  must  be  assured  that  her 
condition  is  not  serious.  Display  of  fear  on  the  part  of  tlie 
nm-se  always  aggravates  this  condition. 

Tetanus. — This  formidable  comphcation  sometimes  follows 
ovariotomy,  as  it  may  follow  any  other  operation.  It  may 
compHcate  a  perfectly  simple  case,  as  in  one  instance  which 
occurred  at  the  Samaritan  Hospital.  This  disease,  rare  as  it  is 
xmder  the  circumstances,  is  generally  in  itself  sufficient  to 
prevent  a  very  long  series  of  ovariotomies  from  shoxsang  one 
hundred  per  cent,  of  recoveries. 

The  sm'geon  must  remember  that  it  has  been  demonstrated 
by  experience  that  faulty  methods  of  seeming  the  pedicle,  and 


TETANUS.  269 

injudicious  meddling  with  its  stump  during  after-treatment, 
are  amongst  the  most  frequent  causes  of  tetanus  after  ovari- 
otomy. Olshausen  shows  that  one  Continental  operator  lost 
seven  out  of  twenty-nine  ovariotomies  through  tetanus  !  There 
was  strong  evidence  that  this  terrible  mortality  was  due  to 
irritation  of  the  pedicle  by  retained  hair-lip  pins,  and  to  its 
frequent  disturbance,  partly,  perhaps,  through  the  over-anxiety 
of  the  operator,  but  in  some  cases,  on  account  of  secondarj^ 
haemorrhage,  which  indicated,  according  to  Olshausen,  an  in- 
sufficient tightness  of  the  clamp  or  ligature,  so  that  the  nerves 
of  the  pedicle  were  not  so  thoroughly  crushed  as  to  be  rendered 
powerless  in  exerting  morbid  reflex  action. 

In  a  case  described  by  Dr.  Gr.  Thomas,  the  tetanic  symptoms 
developed  between  the  tenth  and  fifteenth  day,  and  were  chiefly 
confined  to  trismus  and  pain  in  the  muscles  of  the  neck.  The 
disease  ran  a  chronic  course ;  the  patient  was  kept  quiet, 
hydrate  of  chloral  was  administered  as  an  enema,  and  hypo- 
dermic injections  of  morphine  were  given.  "A  mild  galvanic 
current  was  also  used,  and  the  patient  expressed  herself  as 
feehng  the  better  for  it."      She  recovered. 

Krassowsky,  of  St.  Petersburg,  observed  tetanic  symptoms 
during  ovariotomy  in  two  of  his  patients.  Both  of  these  died 
within  fom-  days,  one  from  internal  hsemorrhage,  the  other 
from  peritonitis. 

From  what  has  been  just  stated,  it  may  be  gleaned  that  no 
special  treatment  of  this  grave  complication  is  of  any  avail. 
Indeed,  the  only  form  of  special  treatment  which  has  been  tried, 
namely,  examination  of  the  pedicle,  appears  to  have  simple- 
aggravated  the  tetanic  spasms.  As  the  clamp  is  now  discarded, 
the  pedicle  is  not  accessible,  and  it  is  not  likely  that  any 
surgeon  would  open  the  abdominal  wound  and  add  a  tighter 
ligature.  Tetanus  must  be  treated,  in  these  cases,  as  it  is 
treated  when  it  complicates  other  diseases.  No  doubt  certain 
practices  and  precautions,  already  described  or  suggested,  will 
tend  to  act  in  a  prophylactic  manner.  The  pedicle  must  be 
tied  as  tightly  as  possible.  The  free  border  of  its  stump,  after 
division,  must  not  be  pulled  about.  The  small  portions  of 
tissue  at  each  end  of  that  border,  held  by  pressm-e-forceps 
dming   the   cleansing  of   the   peritoneum,  as  I  have   already 


270  OVARIOTOMY  :    AFTER-TREATMENT,    ETC. 

directed,  should  be  cut  away  with  the  forceps,  rather  than 
left  behind.  Lastly,  great  care  must  be  taken  to  protect 
the  patient  from  draughts,  even  in  those  climatic  conditions 
where  tetanus  occurs  but  rarely.  In  two  cases  within  my 
knowledge  there  was  a  distinct  history  of  exposure  to  draughts. 
In  a  convalescent  ward  there  is  generally  one  draughty  corner 
at  least,  and  tetanus — or,  more  surely,  other  scarcely  less  dan- 
gerous complications — is  liable  to  attack  mysteriously  the 
patient  whose  bed  lies  in  that  corner. 

Menstruation  after  Ovariotomy:  Haematocele  of 
the  Pedicle. — When  menstruation  occm's  a  few  days  after 
operation,  a  rise  of  temperature  invariably  occurs,  though  some- 
times to  a  very  limited  extent.  Some  writers  beheve  that  the 
show  of  blood,  so  frequently  seen  under  these  circumstances 
before  the  period  is  due,  is  not  truly  menstrual ;  but  this  theory 
is  part  of  a  physiological  question  which  cannot  be  discussed  in 
these  pages.  The  surgeon  should  always  inquire  about  "show" 
when  the  patient's  temperature  rises  during  convalescence  after 
ovariotomy.  "VVTien  this  "  show  "  appears,  there  is  often  more 
or  less  depression  of  spirits,  and  the  pulse  may  rise  con- 
siderably. These  symptoms,  most  marked  in  cases  of  short 
pedicle,  or  sessile  tumours  where  uterine  tissue  is  included  in 
the  hgature,  subside  before  the  "show"  disappears. 

The  patient  must  always  be  warned  to  keep  quiet  during  tlie 
first  two  or  three  periods  after  ovariotomy,  lest  heematocele  of 
the  pedicle  should  occur.  The  symptoms  may  be  alarming, 
though  serious  results  are  rare. 

Notes  of  the  Operation. — It  is  very  advisable  that  the 
sm-geon  should  write  a  note  of  the  operation  as  soon  after  it 
has  been  performed  as  possible.  The  note-book  (page  167) 
must  be  kept  in  the  patient's  room  until  her  discharge.  The 
condition  of  the  pedicle  of  the  pelvic  and  abdominal  viscera 
must  be  noted,  and,  above  all,  the  number  of  sutures  placed 
in  the  abdominal  wound  must  be  recorded  (page  253).  The 
tumom-  should  be  weighed  and  the  fluid  measm-ed.  All  purely 
pathological  researches  must  be  carried  on  outside  the  j)atient's 
chamber. 

The  surgeon  must  insist  upon  the  nurse  writing  down  notes, 
not  only  of  temperatm-e,  but  also  of  diet,  of  the  time  which  the 


NOTES    OF    THE    OPERATION.  271 

patient  spends  in  sleep,  etc.  (page  192).  He  sliould  not  neglect 
to  copy  these  notes,  as  far  as  he  may  deem  them  trustworthy, 
and  add  them  day  by  day  to  his  own  note-book.  In  this  way 
he  will  accumulate  material  of  simply  incalculable  value.  No 
sophistry  about  the  abuse  of  note-taking  must  deter  him  from 
making  short  accm^ate  records  of  his  patients'  condition,  as  far 
as  can  be  done  consistently  with  their  welfare.  At  the  same 
time,  purely  experimental  clinical  work— such  as  digital  ex- 
ploration of  the  vagina  and  bimanual  examination  when  there 
are  no  symjDtoms  of  pelvic  mischief — is  utterly  unjustifiable. 
The  surgeon  should  carefully  endeavour  to  obtain  an  account 
of  each  patient's  condition  a  year  after  the  operation,  entering 
it  in  that  portion  of  the  case-book  which  is  headed  "  Subsequent 
History." 


272 


CHAPTEE  X. 

OOPHORECTOMY   AND   ALLIED   OPERATIOXS. 

Oophorectomy. — By  the  term  oophorectomy,  I  signify  the 
removal  of  one  or  both  of  the  uterine  appendages  for  any 
reason  excepting  the  extirpation  of  what  is  generally  known 
as  an  ovarian  tumour.  The  term  is  open  to  great  objections, 
I  admit,  but  it  is  compact  and  convenient.  Some  operators,  it 
must  be  remembered,  leave  the  ovary  behind  when  removing 
the  tube,  and  there  are  varieties  of  this  operation  to  which 
distinct  names  can  hardly  be  given.  All  other  terms  applied 
to  proceedings  of  this  class  are  equally  open  to  criticism.  The 
sm-geon  should  in  all  cases  specify  what  he  has  removed  in  any 
particular  operation,  then  no  term  which  he  may  choose  to 
employ  can  lead  to  error. 

Oophorectomy  is  performed  in  order  to  check  haemorrhage 
from  fibroid  tumours  of  the  uterus  and  to  arrest  their  growth, 
and  also  in  order  to  remove  hopelessl}^  diseased  ovaries  and 
tubes.  In  the  case  of  a  bleeding  fibroid,  the  operation  has  a 
physiological  aim,  the  induction  of  a  premature  menopause. 
The  removal  of  diseased  appendages  resembles,  to  a  certain 
extent,  the  amputation  of  a  limb  crippled  and  rendered 
dangerous  to  the  organism  by  the  results  of  chronic  inflam- 
matory changes  in  the  bone  or  soft  parts.  In  some  cases  of 
dysmenorrhoca  with  malformed  genitals,  and  in  certain  diseases 
of  the  nervous  system,  oophorectomy  has  been  recommended 
and  performed  with  an  uncertain  degree  of  success.  Many 
authorities  deny  that  this  operation  can  be  justifiable  under 
these  circumstances. 

It  may  well  be  understood  that  it  would  be  out  of  place  for 


INFLAMMATION    OF    THE    APPENDAGES.  273 

me  to  attempt  to  unravel  in  this  manual  the  tangled  skein  of  the 
history  of  oophorectomy.  The  fact  that  this  history  is  in  itself 
so  complicated  has  no  mean  scientific  value.  I  must  refer  the 
reader  to  some  of  the  original  sources  of  information  on  the 
early  history  of  the  subject,*  and  to  the  records  and  opinions  of 
authorities  who  have  within  the  last  few  years  written  and 
spoken  more  or  less  on  their  own  experience.! 

Pathology  of  the  Diseases  where  Oophorectomy 
is  Performed. — Even  were  I  to  exclude  all  neuroses  and  the 
entire  subject  of  dysmenorrhoea  with  or  without  objective 
symptoms,  it  would  yet  remain  impossible  for  me  to  describe 
at  any  length  the  morbid  conditions  where  oophorectomy  may 
offer  a  fair  chance  of  cure  with  the  minimum  of  risk.  I  cannot 
enter  into  the  pathology  of  fibro-myoma  of  the  uterus,  the 
relation  of  that  disease  to  uterine  haemorrhages,  and  the 
physiology  of  the  ovaries  as  far  as  relates  to  those  haemor- 
rhages. Nor  can  I  demonstrate  in  full  those  morbid  changes 
in  the  appendages  which  are  produced  by  inflammatory  condi- 
tions, such  as  pelvic  peritonitis,  inflammation  of  the  ovary, 
inflammation  of  the  Fallopian  tube,  pyosalpinx  and  hydro- 
salpinx. 

Inflammation  of  the  Appendages.  —  Inflammatory 
affections  of  the  appendages  probably  arise,  as  a  rule,  from 
extension  of  inflammation  from  the  vaginal  and  uterine  mucous 
membrane,  which  may  advance  through  the  ostium  of  the  tube 
into  the  peritoneal  cavity  (see  page  17).  Abortion  and  the 
sequelae  of  parturition  at  term  are  by  far  the  most  frequent 
causes  of  these  inflammations,  especially  when  complicated  by 
gonorrhoea.  The  latter  disease  undoubtedly  renders  patients 
liable  to  inflammation  of  the  appendages,  independently  of 
gestation.  As  far  as  I  can  ascertain,  however,  the  patients 
subject  to  this  form  of  inflammation  have  generally  aborted 

*  A  valuable  series  of  references  will  be  found  in  Dr.  Alexander  R.  Simpson's 
"  Histor}^  of  a  Case  of  Double  Oophorectomy  "  {Brit.  Med.  Journal,  vol.  i.,  1879, 
p.  763). 

+  Spencer  "Wells,  Hegar,  and  Battey's  "Symposium  on  Castration  in  Mental 
and  Nervous  Diseases"  {International  Jour.  Med.  Sciences,  October,  1886).  Tait 
"  On  the  General  Principles  involved  in  the  Operation  of  Removal  of  the  Uterine 
Appendages"  {Brit.  Med.  Jounud,  vol.  ii.,  1886,  p.  852),  abstract  of  a  paper 
read  before  the  Medical  Society  of  London. 

T 


274 


OOPHORECTOMY    AXD    ALLIED    OPERATIOXS. 


or  borue  a  child.  Another  cause  of  inflammation  is  a  chill 
during  menstruation.  The  inflamed  tube  becomes  obstructed, 
the  fimbriae  adhering  to  each  other  (Fig.  111).  The  tube 
gradually  swells  through  retention  of  its  secretion,  till  it,  in 
very  rare  cases,  may  form  a  tumom'  rising  above  the  pubes, 
so  as  to  simulate  cystic  ovarian  disease,  as  in  Fig.  112,  which 
represents  the  larger  of  a  pair  of  dropsical  tubes  removed  by 
Sir  Spencer  Wells  from  a  young  woman.  The  tube  may 
be  obstructed  and  filled  A^-ith  a  serous  fluid ;  this  condition 
is  termed  "  hydi'osalpinx."  TVhen  the  fluid  is  purulent,  the 
term   "  pyosalpinx "   is  used ;  it  implies  a  dangerous  form  of 


Fig.  111. — Ax  OBSTRrcTED  Fallopian  Tube. 
The  timbiife  can  still  be  distinguished  on  the  right  hand  of  the  ■\voodcut.     The 
uterine  end,  much  lacerated,  must  not  be  mistaken  for  the  fimbriae.     (3Iuseicm 
JLC.S.,  No.  4,567.) 

disease,  liable  to  set  up  general  peritonitis  thi'ough  rupture  of 
the  tube.  Distension  of  the  tube  with  blood  is  termed  haemato- 
salpinx  ;  this  is  seen  in  inflammation,  but  may  be  due  to  other 
causes.  When  pelvic  peritonitis  occurs  through,  or  independent 
of,  escape  of  inflammatory  material  from  an  unobstructed  tube, 
that  tube  may  become  obstructed  by  bands  of  adhesions.* 

The  ovary  may  inflame,  or  become  surrounded  by  inflamma- 
tory products  interfering  with  its  functions.  After  an  un- 
certain interval  this  organ  becomes  adherent  to  the  tube  and 
broad  ligament,  and  very  often  to  the  omentum.     The  changes 

*  Dr.  Horrocks  has  recently  stated  that,  according  to  post-mortem  evidence, 
tubal  obstruction  is  often  secondary  to  ovarian  inflammation. 


INFLAMMATION    OF    THE    APPENDAGES. 


275 


in  the  substance  of  the  ovary  are  not  thoroughly  understood ; 
suppuration  may  occur.  Its  parenchyma  sometimes  becomes 
abnormally  tough,  and  at  others  undergoes  cystic  degeneration. 
For  a  more  complete  description  of  the  morbid  anatomy  of 
inflamed  appendages,  I  must  refer  the  reader  to  Dr.  Kingston 
Fowler's  "  Contribution  to  the  Pathology  of  Hydro-  and  Pyo- 
salpinx"  (Proc.  Med.  Soc,  vol.  vii.,  1884),  and  to  Mr.  Tait's 


Fig.  112.— a  Fallopian  Tube  Distended  so  as  to  foiim  a  Large 
Cystic  Tumour. 

A  square  i^iece  of  the  Avail  has  been  cut  away  to  expose  the  interior.     {Museum 
ii.C'.>S'.,  No.  4,571.) 

"Fourteen   Specimens   of   Hycbo-   and  Pyosalpinx "    {Trans. 
Path.  Soc,  vol.  xxxiii.,  1882). 
Symptoms  of  Inflammation  of  the  Appendages. — 

The  patient,  generally  after  an  attack  of  acute  pelvic  inflamma- 
tion, suffers  more  or  less  constantly  from  fixed  pain  in  one  or 
both  iliac  fossoB,  pain  dm-ing  coitus,  and  some  disorder  of  men- 
struation, usually  menorrhagia.  Bimanual  examination  must 
be  conducted  on  sound  principles  (see  page  53).     A  solid  body 


276  OOPHORECTOMY    AIS^D    ALLIED    OPERATIONS, 

is  then  detected  on  one  or  both  sides  of  the  uterus.  It  may 
move  with  the  uterus  or  be  fixed,  and  is  almost  invariably 
tender  to  touch.  An  enlarged  and  tender  ovary,  the  seat  of 
chronic  inflammation,  is  more  readily  detected  than  a  dis- 
tended tube. 

When  should  Oophorectomy  be  Performed  ?— In  the 
case  of  a  small  uterine  fibroid  tmnoiu-,  it  is  justifiable  to  remove 
the  ovaries  when  intractable  menorrhagia  has  caused  great 
anaemia.  I  shall  presently  revert  to  the  question  of  oopho- 
rectomy for  the  cure  of  large  fibroids.  I  need  hardly  say  that 
the  sui'geon  must  first  make  sure  that  the  haemorrhage  is  not 
due  to  conditions,  such  as  the  presence  of  a  polypus  of  any  kind, 
to  be  remedied  by  other  means. 

In  the  case  of  inflammatory  diseases  of  the  appendages,  the 
surgeon  should  never  operate  till  after  he  has  had  an  oppor- 
tunity of  watching  the  case  himself  for  several  months,  pre- 
scribing in  the  meanwhile  rest  in  bed,  abstention  from  coitus, 
and  hot-water  vaginal  injections,  followed  by  the  application 
to  the  cervix  of  wool  soaked  in  glycerine  night  and  morning. 
Most  assuredly  some  cases  get  well  under  this  treatment,  as  has 
occurred  twice  in  my  own  experience  after  oophorectomy  had 
been  recommended.  Perhaps  some  allowance  may  be  made 
in  favour  of  the  operation  in  workwomen  of  the  humbler 
classes  who  cannot  rest,  and  who  live  under  conditions  certain 
to  produce  relapse  after  temporary  cure. 

Dr.  Matthews  Duncan*  warns  operators  against  obliterating 
the  distinction  between  the  feasibihty  and  the  advisability  of 
any  operation  of  this  or  any  other  kind,  and  bids  us  beware  of 
maintaining  the  doctrine  that  in  aiming  at  the  relief  of  con- 
tinued suffering,  a  considerable  proportion  of  the  lives  of  the 
sufferers  may  justly  be  sacrificed.  Dr.  Coet  has  issued  the 
important  warning  that  oophorectomy  fails  to  cure  in  many 
cases  where  it  has  been  performed  for  inflammation  of  the 
appendages,  because  the  inflammatory  process  has  already 
spread  over  the  peritoneum  beyond  the  amputated  structures. 

*  "  On  Recent  GyiiiL'Cologj' "  {International  Journal  of  Medical  Sciences,  vol. 
xci.,  p.  89). 

t  "  Is  Disease  of  the  Uterine  Appendages  as  frequent  as  has  been  represented  ?  " 
American  Journal  of  Ohatetrics,  vol.  xi.v.,  1886. 


OOPHORECTOMY    FOR    DISEASE    OF    THE    APPENDAGES.        277 

Conservative  Surgery  in  Inflammation  of  the  Ap- 
pendages.— Efforts  have  been  made  to  examine  inflamed 
appendages  through,  an  abdominal  incision,  and  to  attempt 
to  break  down  adhesions,  and  set  the  tube  and  ovary  straight 
without  removing  them.  Unfortunately,  this  process  is  often 
impossible,  the  parts  being  so  closely  matted  together.  In 
other  cases  it  is  very  dangerous,  owing  to  the  haemorrhage 
which  follows  the  breaking  down  of  adhesions,  or  to  the  risk 
of  rupturing  some  suppurating  structure.  At  the  best,  there 
can  never  be  any  guarantee  that  the  parts  set  straight  will 
resume  their  normal  functions.  Yet  I  believe  that  science 
will  some  day  indicate  a  right  way  to  save  and  cure  inflamed 
ovaries  and  tubes  by  operation. 

Oophorectomy  for  Disease  of  the  Appendages. — 
I  shall  describe  this,  the  more  essential  form  of  oophorectomy, 
first,  and  then  proceed  to  speak  of  removal  of  the  ovaries  for 
the  cure  of  bleeding  fibroids.  The  surgeon  must  banish  from 
his  mind  the  vulgar  error  that  oophorectomy  is  necessarily 
easier  than  ovariotomy.  In  the  former  operation,  now  to  be 
described,  the  abdominal  walls  have  not  been  stretched  by 
the  presence  of  a  large  tumour,  hence  the  operator  will  find 
that  manipulations  are  much  more  difficult  than  during  ovari- 
otomy after  the  cyst  has  been  emptied.  On  account  of  adhe- 
sions and  inflammatory  roughening,  it  becomes  very  hard  to 
distinguish  the  parts  by  touch  or  by  sight. 

The  Operation. — The  patient  must  be  placed  on  the  table, 
as  in  ovariotomy.  A  waterproof  sheet  need  never  be  used,  as 
probably  little  or  no  fluid  will  escape,  but  towels  should  be 
placed  under  the  loins  and  between  the  thighs,  to  catch  any 
blood  which  may  run  down  the  flanks  or  over  the  pubes. 
Another  towel  is  folded  over  the  epigastrium,  and  another 
over  the  upper  part  of  the  thighs.*  The  patient  must  be 
kept  thoroughly  under  the  influence  of  the  ansesthetic.  If 
narcosis  be  incomplete,  the  contractions  of  the  recti  will  greatly 
hinder  manipulations  within  the  abdominal  cavity.  A  sudden 
spasm  of  these  muscles  is  particularly  dangerous  when  the 
surgeon   is   drawing   the    appendages  up  to  the  level  of  the 

*  The  same  instruments  will  be  requned  as  for  ovariotomy  (p.  196),  excepting 
the  ovariotomy-trocar  and  Xelaton's  volsella. 


278  OOPHORECTOMY    AND    ALLIED    OPERATIONS. 

abdominal  wound.  It  ma}'  cause  liim  to  tear  tlie  broad  liga- 
ment. If  the  siu'geon  be  compelled  to  keep  his  hand  for 
many  minutes  within  the  abdomen,  for  the  exploration  of  the 
extent  of  disease  and  the  true  anatomical  relations  of  the 
affected  parts,  muscular  (contractions  will  cause  great  fatigue, 
and  impair  his  sense  of  touch. 

The  Incmon. — The  incision  should  be  commenced  about  three 
inches  below  the  umbilicus,  and  need  not  be  extended  down- 
wards for  more  than  two  inches  and  a  half.  The  walls  are 
generally  more  vascular  than  in  ordinary  ovarian  cases.  On 
opening  the  abdominal  cavity,  the  small  intestines  may  be 
found  in  a  healthy  condition,  and  if  so,  the  surgeon  may  at 
once  pass  his  right  or  left  forefinger  downwards  in  the  direction 
of  the  fundus  uteri,  in  order  to  ascertain  the  extent  and  nature 
of  the  disease. 

Adhesions. — Very  frequently,  however,  the  operator  will  meet 
with  a  difficulty  at  this  stage,  owing  to  omental  adhesions. 
The  omentum,  fortunately,  presents,  as  a  rule,  its  natural 
appearance,  but  may  be  strongly  adherent  to  intestine,  bladder, 
or  uterus.  Irregular  adhesions  to  the  parietal  peritoneum 
are  common  and  puzzling.  I  have  seen  part  of  the  lower 
border  of  the  omentum  dragged  upwards,  and  adherent  to 
the  parietes  not  very  far  below  the  umbilicus,  so  that  a  double 
fold  or  pouch  lay  below  the  point  of  adhesion.  The  two  layers 
of  this  omental  pouch  were  irregularly  adherent  to  each  other 
and  to  adjacent  viscera.  It  is  difficult  to  conceive  any  con- 
dition more  puzzling  at  this  stage  of  the  oj)eration.  The 
omentum  is  sometimes  adherent  to  the  diseased  appendages, 
and  held  down  by  them  in  the  pelvis  ;  this  involves  great 
stretching  of  the  upper  part  of  the  serous  fold,  and  sometimes 
the  transverse  colon  and  stomach  are  much  displaced.  On  the 
other  hand,  the  tube  and  ovary  may  be  drawn  high  up  out 
of  the  pelvis  by  omental  adhesions  (Fig.   113). 

When  the  omentum  is  adherent  to  structui-es  low  down  in 
the  abdominal  cavity,  it  must  be  divided  with  scissors  before 
the  appendages  can  be  reached.  The  free  part  must  be  cut 
through  as  low  down  as  possible  after  pressui'e-forceps  have 
been  placed  on  the  proximal  side  of  the  line  of  division. 
The  omentum   may  be  ligatured   later  in  the  course  of   the 


MANAGEMENT  OF  ADHERENT  OMENTUM. 


279 


operation.  It  is  best  to  apply  a  ligature  to  the  distal  side 
of  the  omentiim  to  be  divided  ;  if  not  the  pressure-forceps  must 
be  used,  and  the  ligature  applied  after  the  omentum  has  been 
cut  through.  The  distal  portion  being  usually  very  vascular, 
should  not  be  detached  from  its  adhesions,  for  it  will  not 
slough,  and  if  torn  off  will  cause  hcemorrhage. 

When   the   omentum   adheres  to   the   diseased   appendages 
themselves,   the    adherent    portion    should    always    be    seized 


Fig.  113. — An  Ovary  strongly  adherent  to  the  Great  Omentum. 

The  ovary  has  become  cystic,  and  a  part  of  the  cyst -wall  has  been  cut  away. 
The  Fallopian  tube  appears  as  a  stout,  tortuous  cord  running  upwards  and  along 
one  side  of  the  ovary.  The  opposite  ovary  formed  a  large  papillomatous  cyst. 
{Museum  B.C. S.,  No.  4,550b.) 

before  division  with  a  pair  of  pressure-forceps,  which  are  then 
entrusted  to  the  assistant.  The  operator  next  passes  a  ligatm-e 
round  the  proximal  side  of  the  piece  of  omentum,  which  is 
then  cut  through.  He  will  find  the  appendages  at  hand,  and 
may  proceed  with  the  next  stage  of  the  operation. 

Exjjloration    of    the    Appendages. — Whether    these    omental 
adhesions   exist   or  not,  the   surgeon  will  have  to  search  for 


280  OOPHORECTOMY    AND    ALLIED    OPERATIONS. 

the  appendages  by  passing  the  fingers  of  his  right  hand 
into  the  pelvic  cavity.  The  forefinger  should  first  be  pressed 
against  the  fundus  of  the  uterus,  and  then  slipped  down  in 
the  direction  of  the  right  appendages.  Now  several  conditions 
may  be  discovered.  The  ovary  and  tube  may  be  diseased,  but 
easily  dra-^m  up.  This  is  not  the  rule.  They  may  be  readily 
pidled  out  of  the  pelvis,  yet  not  without  the  occurrence  of 
profuse  haemorrhage,  caused  by  the  breaking  down  of  adhesions. 
Again,  the}'  may  be  plainl}^  detected  by  the  finger,  yet  not 
easily  moved,  indeed  all  attempts  to  di-aw  them  up  may  be 
of  no  avail.  Lastl}^,  the  appendages  may  be  so  diseased  that 
they  cannot  be  distinguished  by  the  fingers,  or  even  by  inspec- 
tion, facilitated  by  light  thrown  mto  the  pelvic  cavity  by 
means  of  a  hand-glass  or  electric  lamp. 

Removal  of  the  Ajipendage. — The  appendage  to  be  removed 
must,  if  possible,  be  drawn  upwards  to  the  level  of  the  abdo- 
minal wound.  It  is  then  secured  by  a  large  elbowed  pressure- 
forceps,*  so  applied  that  room  is  left  to  pass  the  ligature  needle 
through  the  proximal  side  of  the  pedicle  without  wounding 
the  utems.  The  shape  of  the  blades  allows  the  pedicle  to  be 
held  conveniently,  mthout  any  dragging.  The  blades  should 
be  held  parallel  to  the  abdominal  wound,  and  as  close  to  it 
as  possible.  The  pedicle  is  then  carefully  transfixed  below 
the  blades  (Fig.  114),  and  small  pressm-e-forceps  must  be 
applied  to  each  side  of  the  pedicle  above  them.t  The  assistant 
takes  hold  of  the  large  pressure-forceps,  the  operator  having 
withdrawn  the  ligatm-e  needle  and  seized  the  ligatui-e  silk. 
As  he  begins  to  tie  the  pedicle,  after  the  manner  adopted  in 
ovariotomj'  (p.  220),  the  assistant  takes  off  the  large  pressure- 
forceps,  and  catches  hold  of  the  small  pressure-forceps  abeady 
attached  to  the  appendages.  He  may  have  to  assist  the 
operator,  whose  hands  are  now  occupied  with  the  ligature 
silk,  by  pressing  down  the  abdominal  walls  to  the  level  of 
the  Hgature  with  his  left  hand. 

The  ligature  being   made   fast,  the  operator  takes  hold  of 

*  I  have  alieady  referred  to  this  i)ractice  as  applied  to  ovariotomy  proper  at 
p.  219. 

t  I  do  not  advise  the  inexperienced  to  omit  this  precaution,  as  do  some 
specialists  (see  p.  224). 


REMOVAL    OF    THE    APPENDAGE. 


281 


the  free  end  of  the  appendages  which  he  cuts  away.  The 
assistant  should  keep  hold  of  the  pressure-forceps,  and  they 
ought  not  to  be  removed  until  the  opposite  appendages  have 
been  attended  to.  The  raw  surface  of  the  stump  should  be 
examined  very  carefully,  so  that  the  condition  of  the  tube 
may  be  ascertained.  Should  the  tube  be  diseased,  it  will  not 
be  safe  to  leave  a  piece  of  its  mucous  membrane  projecting 
freely  into  the  peritoneal  cavity,  and  possibly  discharging 
puriform  mucus.      Sometimes,  too,  a  cast  of  a  portion  of  the 


Fig.  114. — Oophorectomy. 

Showing  the  appendages  grasped  by  large  elbowed  pressure-forceps.  The 
pedicle-needle,  bearing  a  loop  of  silk,  perforates  the  broad  ligament  below  the 
forceps  and  near  the  uterus. 


tube,  consisting  of  dried  pus  or  tubercular  matter,  projects 
from  the  cut  surface  of  the  tubal  canal.  Whenever,  then,  the 
exposed  portion  of  tubal  tissue  is  evidently  diseased,  it  is 
advisable  to  touch  the  everted  mucous  membrane  with  the 
point  of  a  Paquelin's  cautery,  or  with  a  drop  of  strong 
solution  of  iodine,  or  of  carbolic  acid  just  melted  from  the 
crystalline  state. 

The  opposite  appendages  must  then  be  searched,  and  treated 
in  the  same  manner,  if  necessary.     In  most  cases  where  this 


282  OOPHORECTOMY    AND    ALLIED    OPERATIONS. 

operation  is  i^erformed  there  is  mucli  capillary  oozing  from 
the  surface  of  the  pelvic  peritoneum,  Avhere  adhesions  have 
been  broken  down.  These  are  best  treated  by  flushing  out 
the  peritoneum  with  water  heated  to  about  100°  (see  j).  236). 
Should  the  oozing  continue  after  free  flushing,  a  drainage- 
tube  must  be  inserted  into  Douglas's  pouch.  The  abdominal 
wound  is  then  sewn  up.  The  after-treatment,  and  the  manage- 
ment of  the  chainage-tube,  will  be  the  same  as  after  ovari- 
otomy. Sometimes  patients  who  have  been  ill  for  a  long  time 
before  operation  are  very  troublesome  dm-ing  convalescence. 
I  do  not  think  that  the  excitability,  intolerance  of  the  slightest 
pain,  and  display  of  ingratitude  and  insubordination  to  medical 
attendants  and  nurses  sometimes  observed  after  oophorectomy 
necessarily  imply  a  psychological  condition  the  direct  result 
of  removal  of  the  appendages.  The  mental  state  is  due 
to  the  demoralizing  effects  of  long-standing  invalidism  of  a 
kind  which  is  rare  in  cases  of  ovarian  tumom-,  but  quite 
common  in  those  disorders  which  demand  oophorectomy. 

The  surgeon  who  proposes  to  perform  this  operation  for 
the  fii'st  time  must  banish  from  his  mind  a  very  misleading 
expression  to  be  found  in  some  text-books,  to  the  effect  that 
the  steps  are  precisely  the  same  as  in  ovariotomj'.  Proper!}' 
speaking,  the  order  in  oophorectomj-,  drawing  a  parallel 
between  it  and  ovariotomy,  and  taking  as  a  guide  my  tabula- 
tion of  the  steps  in  the  latter  ojDeration  at  p.  195  woidd  be 
1,  2,  6,  4,  5,  6,  4,  5,  6,  7,  8,  9,  10,  11.  In  other  words,  after 
making  the  abdominal  incision,  the  surgeon  must  perform  a 
manoeuvre  precisely  similar  to  the  searching  deep  in  the  pelvis 
for  the  ovary  opposite  to  that  which  is  the  site  of  the  tmnour, 
and  having  found  it,  to  extract  it  through  the  abdominal 
wound,  attending  to  adhesions,  to  apply  the  ligature,  and 
then  to  divide  the  pedicle  ;  the  whole  process  is  then  repeated 
on  the  opposite  side.  There  is  nothing  homologous  to  step  3 
in  oophorectomy,  and  in  this  operation  step  4  will  not  involve 
tapping. 

Oophorectomy  for  Neurotic  Conditions,  etc. — When 
the  surgeon  deems  it  justifiable  to  remove  the  appendages  for 
the  relief  of  some  nervous  affection — a  step  never  to  be  taken 
without  grave  deliberation  and   long   personal   experience  of 


OOPHORECTOMY   FOR   ^'E^ROSES    AND    FOR    FIBROID    DISEASE.      283 

the  nervous  diseases  of  women, — the  operation  will  be  per- 
formed in  the  manner  described  above.  Should  the  appendages 
be  healthy,  the  operation  will  not  be  very  difficult;  but  they 
often  prove  to  be  diseased. 

Oophorectomy  in  Fibroid  Disease  of  the  Uterus. — 
The  uterine  appendages  are  sometimes  removed  to  check 
hsemorrhage  in  cases  of  fibroid  disease  of  the  uterus,  where 
that  symptom  has  become  serious.  Some  surgeons  perform 
this  operation  for  the  same  disease,  not  with  the  view  of 
checking  hsemorrhage,  which  may  or  may  not  exist,  but  to 
arrest  the  growth  of  the  tumour.  When  the  uterine  tumour 
is  small,  the  operation  is  relatively  easy,  and  would  then 
appear  to  be  quite  justifiable  when  much  haemorrhage  has 
taken  place.  When  the  tumour  is  large,  the  operation  is 
always  difficult  and  dangerous,  indeed  it  may  become  im- 
possible. 

In  removal  of  the  appendages  for  ciu-e  of  a  small  bleeding 
fibroid,  the  patient  is  prepared  in  the  manner  already  described 
in  relation  to  oophorectomy  for  disease  of  the  appendages.  The 
abdominal  incision  should  be  about  three  inches  long,  as  there 
will  be  a  timiour  in  the  way  of  the  operator's  hand  throughout 
the  subsequent  proceedings.  The  surgeon  must  bear  in  mind 
the  possibility  that  the  bladder  may  be  somewhat  displaced. 
When  the  peritoneal  cavity  is  opened,  the  uterine  tmuour  must 
be  closely  inspected,  and  care  is  particularly  needed  if  there 
be  one  or  more  subperitoneal  outgrowths  springing  from  short, 
thin  pedicles  on  the  surface  of  the  uterus.  If  such  an  out- 
growth be  torn  off,  as  may  very  probably  happen  should  the 
operator  catch  hold  of  it  for  the  purpose  of  altering  the  position 
of  the  uterus,  serious  haemorrhage  may  ensue,  and  probably 
supra-vaginal  amputation  of  the  uterus  will  be  needed. 

The  operator  must  sHp  the  fore  and  middle  fingers  of  one 
hand  over  one  side  of  the  uterus  till  the  appendages  are 
reached;  often  the  junction  of  the  tube  with  the  fundus  is 
within  sight,  and  in  any  case  the  tube  is  the  best  guide,  to  the 
touch  as  well  as  to  the  eye.  In  some  cases  it  is  best  to  explore 
with  all  four  fingers.  The  tube  and  ovary  are  now  drawn  up 
out  of  the  abdominal  wound.  They  will  generally  be  found  free 
from  adhesions,  but  exceedingly  vascular.  .  The  broad  ligament 


284  OOPHORECTOMY   AND   ALLIED    OPERATIONS. 

is  transfixed  and  secured  by  ligature  as  in  ovariotomj;  the 
needle  should  be  passed  through  it  about  half  an  inch  from  the 
uterus.  Pressure-forceps  should  be  fixed  to  the  two  extremities 
of  the  pedicle  on  the  distal  side  of  the  ligature  before  the  pedicle 
is  divided,  and  left  on  the  stump  of  the  pedicle.  The  reasons 
for  this  step  are  given  at  page  224.  It  is  especially  important 
that  the  stump  should  be  inspected  before  closing  the  abdominal 
wound,  and  the  precaution  just  noted  facilitates  the  inspection 
and  renders  it  safe. 

The  opposite  appendages  are  treated  in  the  same  way  ;  then 
the  stumps  of  the  pedicles  are  thoroughly  examined.  It  is 
best,  after  securing  the  transfijxing  ligatm'es  on  each  side,  to 
pass  a  single  loop  of  No.  3  silk  round  the  pedicle  and  tie 
it  tight,  making  sure  that  it  slips  accurately  into  the  groove 
already  made  by  the  former  ligatures. 

When  the  fibroid  tumour  of  the  uterus  is  large,  this  operation 
wdll  never  be  safe  and  wall  often  be  difficult.  The  distortions  of 
the  uterus  caused  by  large  fibroid  growths  will  be  noted  (see 
Eig.  115,  page  291).  These  distortions  displace  the  appendages. 
The  fundus  may  be  rotated  so  that  one  extremity  looks  almost 
directly  backwards,  or  backwards  and  downwards,  or  simply 
downwards.  One  ovarj'  will  then  lie  almost  in  fi'ont,  or  high 
in  the  pelvis  laterallj^  the  other  will  then  be  behind  the  great 
tumour  or  deep  in  the  pelvis.  Occasionally,  one  appendage 
wdll  be  hidden,  or  practically  inaccessible,  in  a  deep  groove 
between  two  outgrowths  from  the  siu-face  of  the  tumour.  The 
most  serious  condition,  however,  is  that  where,  on  raising  the 
appendages  on  one  side,  the  broad  ligament  is  seen  to  form  a 
pyramid  with  its  base  on  the  side  of  the  tumour — that  is  to  say, 
when  its  two  folds  have  been  wddely  parted  along  their  line  of 
reflection  on  to  the  uterus.  Large  vessels  run  behind  each  fold, 
lying  far  apart  from  each  other  towards  the  base  of  the  pjTamid. 
Now  the  apex  of  the  pyramid  is  formed  by  the  ovary  and  the 
outer  part  of  the  tube  held  up  in  the  surgeon's  hand,  and  the 
ligatures  must  be  passed  through  the  middle  of  the  pyramid. 
This  condition  I  have  witnessed  more  than  once  with  my  own 
eyes.  It  is  self-evident  that  the  chances  that  the  large  and 
tiu'gid  vessels  will  slip  must  be  great,  for  the  broad  ligament 
becomes  very  tense    when   its  layers  are  pulled  tight  by  the 


OOPHORECTOMY    FOR    FIBROID    DISEASE AFTER-TREATMENT.      285 

ligature.  Hence,  as  I  have  seen,  some  of  the  vessels  may  slip, 
fortunately,  in  a  few  minutes,  before  the  close  of  the  operation. 
Hsemorrhage  is  then  very  difficult  to  check,  as  the  vessels 
retract  far  in  the  overgrown  connective  tissue  of  the  broad 
ligament.  In  one  case  where  I  assisted,  the  uterus  had  to  be 
amputated  as  in  ordinary  hysterectomy  before  the  haemorrhage 
could  be  checked.  This  has  occurred  in  the  experience  of 
several  operators. 

Hence  when  the  appendages  are  inaccessible,  the  operation 
will  have  to  be  abandoned,  or  hysterectomy  must  be  performed. 
When  the  layers  of  the  broad  ligament  are  widely  parted  close 
to  the  tumour,  so  that  when  the  ovary  is  raised  the  ligament 
forms  a  pyramid  in  the  manner  described  above,  it  will  also  be 
safer  to  amputate  the  uterus.  Should  the  operator  be  determined 
to  remove  the  appendages  only,  he  had  better  secure  the  large 
vessels  separately  along  the  same  level,  and  then  transfix  and 
tie  the  ligatures  along  that  level. 

After-Treatment. — In  all  cases  of  oophorectomy  the 
principles  which  guide  the  surgeon  in  his  after-treatment  of 
an  ovariotomy  must  be  strictly  observed.  Above  all,  he  must 
take  every  step  within  his  power  to  obtain  the  after-history  of 
every  case,  never  losing  sight  of  it  as  long  as  the  patient's 
address  remains  known  to  him. 

Results. — No  satisfactory  idea  of  the  results  of  oophorectomy 
can  be  given  by  statistics.  The  operation  requires  much  skill 
and  experience  to  ensure  anything  like  safety  to  life,  and  the 
low  percentages  of  mortality  which  have  been  published  depend 
therefore  on  the  operator  rather  than  on  the  operation. 
Bantock,  Thornton,  Tait,  and  Keith,  however,  have  all  shown 
that  the  mortality  after  oophorectomy  is  distinctly  higher  than 
that  after  ovariotom}',  in  their  own  experience.  The  danger  of 
fatal  hsemorrhage  after  removal  of  the  appendages  for  fibroid 
disease  of  the  uterus  is,  to  my  knowledge,  considerable,  and 
recovery  from  the  same  operation  when  performed  for  disease 
of  the  appendages  does  not  invariably  mean  relief  of  the 
symptoms.  It  is  neither  probable  nor  advisable  that  the  opera- 
tion will  ever  be  performed  largely  by  general  surgeons,  as  is 
the  case  with  ovariotomy  at  the  present  day. 


286 


CHAPTEE  XI. 

SUPRA-YAGINAL   HYSTERECTOMY— OPERATIOXS   OX   FIBROID 
TUMOURS  AXD   POLYPI. 

Operations  for  the  Removal  of  Uterine  Fibroids. — I 

shall  tliroiigliout  this  chapter  employ  the  term  "  fibroid,"  as  it 
is  convenient  and  universally  understood,  although  I  admit  that 
the  exigencies  of  pathology  demand  a  more  accurate  nomencla- 
tare.  For  the  pathology  of  all  forms  of  myoma  or  fibro-myoma 
of  the  uterus,  I  must  refer  the  reader  to  systematic  text-books. 
The  ethical  aspect  of  the  question  of  operation  has  been  the 
subject  of  grave  controversy.  Distinguished  British  and  foreign 
specialists  are  much  di"vdded  in  opinion  on  the  matter.  I  recom- 
mend the  reader  to  consult  g;yTisecological  literature  for  the  last 
ten  years,  and  to  judge  for  himself  of  the  opinions  of  Spencer 
Wells,  Keith,  Tait,  Bantock,  Thornton,  and  others,  who  can 
claim  authority  through  long  experience. 

I  shall  content  myself  wdth  remarking  that  uterine  fibroids 
do  not  advance  steadily  to  the  destruction  of  life  after  the 
manner  of  cystic  ovarian  tumours,  but  some  forms,  indej)endent 
of  fibroid  polypi  and  allied  conditions  which  can  be  operated 
upon  tlu'ough  the  vagina,  damage  the  patient's  health,  and  even 
put  her  life  in  danger  through  frequent  haemorrhage.  A  very 
large  fibroid  may  cause  certain  ■  and  permanent  misery,  and  no 
small  risk  to  life  even  when  there  are  no  hcemorrhages.  On 
the  other  hand,  the  removal  of  a  large  fibroid  is  undoubtedly 
dangerous.  I  believe,  however,  that  oophorectomy  for  a  large 
fibroid  is  yet  more  dangerous  (see  page  284).  Hence,  after  due 
deliberation,  I  consider  that  it  is  justifiable  to  remove  a  large 
fibroid  tumour  of  the  uterus  in  a  patient  far  from  the  meno- 
pause, if  it  be  the  cause  of  permanent  ill-health  and  discomfoi't 


SUPRA-VAGINAL    HYSTEEECTOMY.  287 

throngh  its  size  or  tkrough  metrorrliagia.  Small  bleeding 
fibroids  are  best  left  alone,  or  else  oophorectomy  may  be  under- 
taken.    Small  fibroids  that  do  not  bleed  should  not  be  touched. 

I  shall  first  describe  the  operation  of  amputation  of  the  bodj-  of 
the  uterus,  or  supra-vaginal  hysterectomy,  as  performed  at  the 
Samaritan  Hospital  by  Dr.  Bantock.  I  have  had  the  oppor- 
tunity of  assisting  that  surgeon  at .  a  large  number  of  these 
operations  at  that  institution,  and  the  following  description  is 
based  on  notes  taken  after  the  conclusion  of  each  case.  This 
operation,  though  almost  invariably  performed  for  the  removal 
of  general  fibroid  enlargements  of  the  uterus,  may  be  deemed 
necessary  for  sarcoma  of  the  body  of  that  organ,  or  even  for 
cancer  in  the  same  anatomical  locality.  It  may  also  be  said 
to  form  a  part  of  Porro's  operation.  In  some  cases  of  ovari- 
otomy, and  oophorectomy,  hj^sterectomy  becomes  a  necessity  as 
the  only  means  of  checking  dangerous  haemorrhage. 

Supra- Vaginal  Hysterectomy. — The  surgeon,  assistant, 
and  nurses,  should  take  up  the  same  positions  as  at  an  ovari- 
otomy (page  200).  The  same  instruments  will  be  required 
(page  196),  except  the  trocar  and  cannula  which  is  replaced 
by  Koeberle's  serre-noeud  (page  122)  in  three  sizes,  with  several 
wires  and  a  pair  of  nippers.  Care  should  be  taken  that  they 
are  clean,  dry,  and  in  working  order.  Above  all,  the  operator 
must  see  that  the  key  is  not  forgotten,  else  the  screw  cannot  be 
tm-ned.  The  pedicle-needles  (page  112)  should  be  at  hand,  as 
the  appendages  may  require  ligature.  A  Tait's  screw,  an  in- 
strument which  resembles  a  large  corkscrew,  will  prove  useful. 

A  single  assistant  is  quite  sufficient,  though  towards  the  end 
of  the  operation  somebody  should  be  at  hand  to  hold  the  string 
that  keeps  the  pins  and  the  pedicle  well  dovoi  whilst  the  abdo- 
minal wound  is  being  closed,  in  the  manner  which  will  presently 
be  explained.  The  manoeuvres  in  hj^sterectomy  are  complicated, 
but  at  the  same  time  they  are  of  such  a  nature  as  to  be  best 
conducted  by  two  persons.  The  waterproof  sheet  is  not  neces- 
sary, as  no  mass  of  fiuid  will  escape  from  the  tumour ;  the 
abdomen  is  protected  by  the  arrangements  noted  in  the  chapter 
on  oophorectom}'.  The  surgeon  and  assistant  must  have  their 
sleeves  tucked  up  as  high  as  possible.  Bare  arms  are  more 
readily  cleaned  than   mackintosh  sleeves,  but  the  shu"t-sleeves 


288  SUPRA-VAGINAL    HYSTERECTOMY. 

must  be  kept  out  of  danger,  as  the  fear  of  soiling  them  may 
worry  the  of)erator  and  so  interfere  with  his  movements.  The 
operator's  and  assistant's  aprons  should  be  long  enough  to  pro- 
tect the  lower  part  of  their  dress  and  boots  from  blood. 

The  Abdominal  Wound. — An  incision  about  tlu-ee  inches 
in  length  is  now  made  in  the  middle  line,  as  in  ovariotomy. 
The  bladder  must  be  borne  in  mind,  as  there  is  sometimes  con- 
siderable difficulty  in  emptying  it  artificially,  even  when  the 
nurse  thoroughly  understands  the  use  of  the  catheter.  There 
is  far  more  risk  of  injuring  the  bladder  in  hysterectomy  than 
in  ovariotomy.  The  abdominal  walls  are  also  very  vascular  in 
fibroid  disease.  Indeed,  the  free  htemorrhage  which  follows 
the  incision  is  almost  diagnostic  in  doubtful  cases.  The  assist- 
ant must  use  his  sponges  freely,  and  the  surgeon  will  require 
the  aid  of  the  pressure-forceps.  When  the  peritoneum  is 
divided,  if  diagnosis  be  accurate,  the  characteristic  pale  brick- 
red  surface  of  the  tumour  will  be  observed.  If  there  be  much 
fibrous  tissue,  the  sm-face  will  be  very  pale  and  almost  silvery, 
as  in  some  ovarian  tumoi^rs.  In  cases  where  repeated  hsemor- 
rhages  have  occurred  and  the  patient  has  become  exceedingly 
anaemic,  the  tumour  is  often  of  a  pale  yellow  colour,  like  a 
sarcoma  or  a  mass  of  fat. 

Exploration  of  the  Tumour. — The  first  thing  to  be 
determined  will  be  the  pelvic  relations  of  the  tumour  and  the 
possibility  of  its  removal  without  too  great  risk.  If  it  be  found 
that  the  broad  ligaments  are  not  opened  up  by  extensive  lateral 
growth  of  the  tumour,  then  it  may  be  desu-able  to  ascertain 
whether  there  be  adhesions  to  the  parietes  and  other  structm-es. 
This  can  be  done  by  the  forefinger,  passed  down  to  the  level  of 
the  pelvic  brim  on  each  side. 

As  a  rule,  the  incision  will  require  considerable  extension 
upwards  in  proportion  to  the  size  of  the  tumom-.  A  fibroid 
cannot  be  pulled  out  of  the  abdomen  unless  the  incision  extend 
almost  as  high  as  its  upper  border,  especially  if  it  be  broad.  In 
pulling  the  tumour  through  a  small  opening,  outgrowths  may 
be  torn  off,  and  this  may  cause  troublesome  hajmon-hage. 
Besides,  it  is  most  important  to  be  able  to  find  out  adhesions 
above.  There  is  no  objection  to  using  the  scissors  ;  indeed,  it 
is   safer  than   the  knife   if  the    assistant  guard  the  structm-es 


EXPI.ORATION    OF    TUMOUR MANAGEMENT    OF    ADHESIONS.    289 

behind  with  a  sponge.  The  umbilicus  may  be  cut  through,  and 
its  tissues  should  be  dissected  away  before  the  wound  is  closed.* 
Those  wlio  hold  that  foetal  relic  is  sacred  may  cut  to  its  left  side. 

Inspection  and  Management  of  Adhesions. — The 
adhesions  in  front  must  be  divided  before  the  tumour  is  raised 
out  of  the  abdomen.  Parietal  adhesions,  so  frequent  in  ovarian 
timiours,  are  rare  in  these  cases.  On  the  other  hand,  intimate 
connections  between  the  omentum  and  the  fibroid  are  very 
common.  The  omentum  undergoes  a  remarkable  hypertropliy 
when  this  condition  has  lasted  long.  The  vessels  become 
enormously  enlarged.  The  great  veins,  tlie  arteries  sometimes 
of  the  calibre  of  the  radial,  pulsating  visibly,  and  the  lymphatic 
vessels,  in  some  cases  widely  dilated,t  may  startle  even  a  bold 
operator.  Another  difficulty  may  be  experienced,  for  the  con- 
nective tissue  of  the  omentum  occasionally  undergoes  patholo- 
gical changes,  so  that  it  is  hard  to  get  well  behind  a  distinct 
piece  of  omentum.  Owing  to  atrophy  of  the  omental  tissues 
around  them,  some  of  the  vessels  may  run  for  an  inch  or  more 
almost  separate  from  any  other  structure  and  well  to  the  front, 
whilst  others  run  closely  adherent  to  the  surface  of  the  tumour 
behind  tlie  main  part  of  tlie  omentum. 

Where  this  condition  exists,  the  omentum  must  be  traced 
upwards  and  secui-ed  above  the  level  of  the  tumour,  even  if 
that  point  lie  close  to  the  transverse  colon.  A  No.  3  silk 
ligature  must  be  passed  througli  the  omentum  and  one  side 
secm-ed,  then  the  opposite  side  is  tied  with  the  same  material. 
If,  however,  the  vessels  be  very  large,  tlie  omentum  will  have  to 
be  tied  in  several  pieces,  and  the  surgeon  may  ligature  some  of 
the  larger  vessels  separately.  Before  dividing  the  ligatm-ed 
parts,  the  distal  portions  must  be  carefully  secui-ed.  If  this 
be  neglected,  dangerous  haemorrhage  may  follow,  for  the 
circulation  in  the  uterus  and  the  tumour  is,  at  this  stage,  still 

*  This  will  cause  the  wound  to  be  firmer,  at  the  level  of  the  umbilicus,  than 
when  the  umbilical  tissues  are  left  behind. 

t  They  do  not  enlarge  so  frequently  as  the  blood-vessels,  but  in  one  case  I 
observed  a  complete  plexus  of  lymphatic  vessels  of  about  the  calibre  of  the 
dorsalis  pedis  artery.  The  constrictions  marking  the  valves  were  characteristic, 
and  gave  a  remarkable  appearance,  as  though  white  beads  had  been  embroidered 
int©  the  omentum  along  the  course  of  the  blood-vessels. 

U 


290  SUPRA- VAGINAL    HYSTERECTOMY. 

continuing  actively.  Each  distal  portion  should  be  secured  by 
pressui'e-forceps,  small  or  large,  according  to  circumstances. 
In  many  cases  it  is  perhaps  best  to  economize  forceps  by 
tying  the  distal  portion  carefully,  but  this  takes  up  time  in 
an  operation  which  is  in  itself  lengthy.  The  omentum  being 
thus  secm^ed,  it  is  divided.  The  proximal  portion  is  returned 
into  the  abdomen,  guarded  by  a  large  flat  sponge.  I  may  here 
observe  that  the  dilated  omental  vessels  are  seldom  a  source  of 
danger  when  properly  seciu-ed.  They  rapidly  dwindle  in  size 
after  the  mass  which  they  formerly  supplied  has  been  removed. 

Intestinal  adhesions  require  very  great  care  in  management. 
When  in  process  of  separation,  some  of  the  uterine  tissue  may 
be  torn,  and  then  a  kind  of  active  capillary  hoemorrhage  follows 
which  cannot  possibl}^  be  stopped  by  ligatures.  It  is  best 
checked  by  the  pressure  of  a  sponge,  which  the  assistant  must 
hold  against  the  bleeding  spot.  This  compHcation  must 
sometimes  be  dehberately  incurred,  since  it  is  far  less  serious 
than  laceration  of  the  intestine. 

Extraction  of  the  Tumour. — Adhesions  having  been 
freed,  the  tumour  is  now  pulled  out  of  the  wound.  If  it  be 
evidently  finn,  Tait's  corkscrew  may  be  thrust  into  its  most 
prominent  part.  The  operator  then  pulls  forwards  until  the 
tumour  comes  out.  Soft  fibroids,  however,  cannot  be  treated 
in  this  manner ;  the  corkscrew  drags  out  when  firmly  pulled 
upon,  and  troublesome  hoemorrhage  occm's.  Such  a  tumour 
must  be  deliberately  lifted  out,  the  operator  slipping  his  hands 
over  the  fundus  and  pulling  forwards.  Some  operators  employ, 
at  this  stage,  a  large  instrument  something  like  lion-forceps, 
with  the  blades  mounted  scissors-fashion,  and  with  a  wide  gape 
and  a  firm  grip.  "Where  the  corkscrew  fails,  however,  the 
forceps  will  be  as  likely  to  tear  away  part  of  the  tumom-  as 
to  haul  it  out  entire.  As  the  tumour  comes  out,  a  large  flat 
sponge  sliould  be  placed  over  the  viscera  and  pushed  imder  the 
parietes,  partly  above  the  upper  angle  of  the  abdominal 
wound.* 

Examination  of  the  Relations  of  the  Uterus.— The 

When  tliis  wound  is  very  long  it  is  advisable  to  close  two  or  three  inches  of 
its  upper  part,  or,  at  least,  to  introduce  one  suture  at  this  stage,  to  prevent  the 
escape  of  intestines  through  a  sudden  action  of  the  abdominal  muscles. 


EXAMINATION  OF  THE  RELATIONS  OF  THE  UTERUS.   291 

tmnour  having  been  extracted,  the  surgeon  will  have  to 
examine  its  lower  part,  in  order  to  make  sure  of  its  relations 
to  the  portion  of  the  uterus  not  involved,  to  the  appendages,  to 
the  cervix,  and  to  the  bladder.  The  broad  ligaments  are  the 
best  guides  whenever  the  fundus  is  out  of  sight,  or  merged  into 
the  general  mass  of  the  tumour.  They  often  are  subject,  in 
these  cases,  to  a  remarkable  pathological  change,  very  jDuzzKng 
to  the  operator  if  he  has  never  seen  them  previously.  In  this 
case  their  com"se  is  indicated  by  large  thin-wailed  cystoid 
bodies  containing  a  yellowish  fluid,  running  downwards  and 
outwards  from  each  side  of  the  tumour.     These  bodies  form 


•*^  L% 


Fig.  115. — A  Fibroid  Uterus  seex  from  the  Front. 
The  pedicle  is  narrow.     The  natural  position  of  the  appendages  is  altered,  so 
that  the  left  tube  and  ovary  lie  almost  on  the  front  of  the  tumour.     (From  a 
sketch  made  by  the  author  directly  after  the  removal  of  the  specimen.) 

two  collections  of  bullae,  completely  conceahng  the  Fallopian 
tubes.  On  careful  inspection,  the  tubes,  the  ovaries,  and  the 
engorged  vessels  in  the  broad  ligament  may  readily  be  detected. 
The  bodies  are  the  l-ijstes  lacunniv  or  hygromes  sous-sereux  o£ 
Yerneuil,  and  are  quite  different  from  thin-walled  broad  liga- 
ment cysts.  They  appear  to  be  due  to  a  simple  long-standing 
oedema  of  the  broad  ligaments,  and  disappear  entirely  when  the 
adjacent  structm-es  are  divided  in  the  later  stages  of  the  ojDera- 
tion.  When  one  of  these  cystoid  structures  bursts  in  the  com-se 
of  an  operation,  the  escaping  fluid  may  be  taken  for  mine,  to 
the  great  alarm  of  the  operator. 


292  SUPRA- VAGINAL    HYSTERECTOMY. 

The  ligaments,  as  a  rule,  proceed  from  the  sides  of  the 
tumour,  somewhat  anteriorly,  and  never  quite  sj'mmetrically. 
But  one,  or  even  both,  may  come  from  the  back  of  the 
tumour. 

In  some  cases  (Fig.  115),  the  natm-al  axes  of  the  pelvic 
organs  are  entirely  altered  b}"  unsymmetrical  growth  of  a  large 
fibroid  or  of  several  fibroid  outgrowths.  Hence,  the  search  for 
the  appendages  may  be  attended  with  great  difficulties.  When 
found,  their  treatment  depends  very  much  on  their  position. 
This  question  is  closely  related  to  the  next  stage  of  the 
operation.  The  ovaries  vary  greatly  in  appearance.  They  are 
generally  swollen,  with  large  follicles,  often  full  of  blood, 
projecting  from  their  free  surfaces.  On  the  other  hand,  I  have 
seen  them  stretched  and  flattened,  so  as  to  look  like  white 
ribbons,  hardly  wider  than  the  ovarian  ligaments. 

The  Level  of  the  Pedicle. — The  wire  of  a  Koeberle's 
clamp  must  now  be  passed  round  the  pedicle.  This  involves 
three  practical  questions.  Firstlj^  the  nature  of  the  pedicle 
must  be  remembered.  Then  the  treatment  of  the  appendages 
must  be  considered.  Lastly,  when  it  is  decided  to  pass  the 
wire  roimd  the  tumour  at  a  certain  level,  the  protection  of 
important  anatomical  structiu-es  must  not  be  overlooked. 

Before  discussing  these  serious  questions,  I  must  observe 
that  the  practice  of  applying  large  pressm^e-forceps,  elastic 
ligatures,  or  temporary  clamps  of  any  kind,  to  the  pedicle, 
cutting  away  the  tumom-,  and  then  applying  the  serre-noeud, 
involves  great  dangers  and  difficulties.  Hard  as  it  may  some- 
times be  to  distinguish  the  relations  of  the  pedicle  before  the 
removal  of  the  tumom^,  the  task  becomes  far  harder  afterwards, 
and  the  risk  of  damaging  the  bladder  or  a  ureter  will  be 
greater.  The  application  of  the  serre-nceud  and  pins  will  also 
be  very  troublesome.  There  may  be  cases  where  this  practice 
of  applying  the  serre-noeud  to  the  pedicle  after  the  removal 
of  the  tumour  is  justifiable,  but  such  cases  are  exceedingly 
rare.  The  inexperienced  are  liable  to  get  into  great  trouble 
over  a  divided  stump  of  a  uterine  pedicle  not  properly  secured. 
The  pedicle  is  simply  the  lower  part  of  the  uterus  or  the 
upper  part  of  the  cervix.  When  the  enlargement  lies  chiefly 
towards  the  fundus,  and  when,  at  the  same  time,  the  appendages 


THE    LE^'EL    OF    THE    PEDICLE ENUCLEATION. 


293 


proceed  from  the  sides  of  the  tiimour  symmetrically,  so  that  it 
is  evident  that  the  wire  can  readily  be  passed  round  the  lower 
part  of  the  uterus,  below  them,  there  will  be  little  ditSculty 
in  this  stage  of  the  operation.  Often,  however,  the  tumour 
invades  the  lower  part  of  the  uterus  (Fig.  116),  or,  what  is  still 
more  frequent,  small  dense  fibro-myomata  are  developed  in  its 
walls  at  the  level  of  the  proposed  pedicle.  In  these  cases  it  may 
be  necessary  to  shell  the  tumour  out  of  its  capsule.  A  scalpel 
is  passed  horizontally  round  the  growth  so  as  to  divide  the  cap- 


FiG.  116. — A  Fibroid  Uteexis  Removed  during  Life. 

The  uterine  cavity  is  laid  open,  showing  interstitial  growths  bulging  into 
it.  Similar  growths  lay  in  the  part  of  the  uterine  walls  through  which  the  knife 
passed. 

sule,  which  is  peeled  off  below  the  incision,  bleeding  vessels 
being  secured  by  pressure-forceps.  When  the  tumour  is 
sufficiently  enucleated  the  wire  loop  and  pins  are  appKed  to 
the  portion  of  the  capsule  which  is  left  behind. 

The  relations  of  the  appendages  to  the  proposed  pedicle 
must  also  be  ascertained.  When  they  lie  even,  and  high  up  on 
the  sides  of  the  tumour,  the  wire  may  be  passed  entirely  under 
them ;  that  is  to  say,  as  the  wire  is  slipped  round  the  pedicle, 
the  tubes,  ovaries,  and  greater  part  of  the  broad  ligaments  are 


294 


SUPRA- VAGINAL    HYSTERECTOMY. 


held  or  piilled,  bj  the  assistant,  well  above  the  level  of  the  loop 
of  wire,  which  will  grasp  them,  as  experience  has  proved,  with 
sufficient  firmness.  Sometimes,  however,  one  or  both  append- 
ages lie  too  low  for  this  kind  of  treatment  (Fig.  117),  for  the 
wii'e  cannot  be  safely  passed  round  the  middle  of  the  append- 
ages, which  are  often  tense,  so  that  the  proximal  part  will  not 
be  secure  against  hcemorrhage  after  the  tumom"  has  been  cut 
away. 

Management  of  the  Uterine  Appendages. — The  best 
way  of  dealing  with  an  appendage  placed  too  low  to  be  included 
in  the  loop  is  to  remove  it,  as  in  oophorectomy.  When  the 
appendages  he  unsymmetricall}',  as  abeady  described,  the  lower 
often   requires   separate   removal,   whilst    the    higher   can   be 


Fig.  117. — A  Fibkoid  Utep.us. 

The  pedicle  is  very  broad.  In  tliis  case  the  appendages  required  separate 
ligature.  (From  a  sketch  by  the  author  made  directly  after  the  removal  of  the 
tumour  ;   the  appendages  are  represented  entire,  as  though  undivided.) 


included  in  the  -^Ti-e  loop  of  the  serre-nceud.  The  details  of 
the  process  of  removal  are  described  at  page  280,  and  illus- 
trated by  a  drawing  (Fig.  114). 

Lastly,  before  the  wire  is  passed  round  the  tumom\  the 
position  of  the  bladder  must  be  noted.  It  is  sometimes 
drawn  up  on  the  surface  of  the  tumoiu'.  In  such  cases,  it 
may  be  desirable  to  pass  a  catheter  in  order  to  ascertain  the 
position  of  the  fundus.  It  will  be  a  valuable  guide  to  the 
operator,  who  will  see  its  point  pushing  the  fundus  of  the 
bladder  upwards.  I  have  twice  seen  the  fundus  accidentally 
and  inadvertently  included  in  the  wire,  and  cut  across  duiing 
the  division  of  the  pedicle.     In  both  cases  the  patient  died.     In 


APPLICATION    OF    WIRE    LOOP    AND    PINS.  295 

one,  at  least,  the  wire  appears  to  have  slipped  downwards  over 
the  bladder  during  the  process  of  tightening. 

The  operator  must  also  see  how  the  loop  lies  posteriorly,  and 
must  keep  the  intestine  out  of  its  way,  and  above  any  suspicious 
peritoneal  folds  in  the  pelvis. 

Application  of  the  Wire  Loop. — All  the  above  pre- 
cautions being  considered,  the  surgeon,  having  settled  the 
level,  which  should  always  be,  if  possible,  a  little  above  the 
OS  internum,  passes  the  wire  loop  round  the  pedicle.  The 
assistant  must  hold  the  tumour  well  up. 

Whilst  the  intestines  are  protected  by  a  flat  sponge,  the  free 
end  of  the  wire  is  carried  round  the  pedicle,  j^assed  under  the 
bridge  at  the  end  of  the  serre-nceud,  and  twisted  round  the 
button  (see  Fig.  52).  The  wire  is  then  tightened  by  means 
of  the  key,  and  care  must  be  taken  not  to  use  so  much  force 
as  to  cut  the  tissues  or  snap  the  wire. 

Application  of  the  Pins. — When  the  wire  loop  has  been 
properly  tightened,  the  pins  (page  124)  must  be  passed  through 
the  pedicle  close  to  the  wire,  and  on  its  distal  side.  I  have 
heard  of  the  pins  being  passed  on  the  proximal  or  cervical 
side  of  the  wire  loop.  This  practice  is  not  in  accordance  with 
the  principle  on  which  the  pins  should  be  applied,  for  they  are 
meant  to  support  the  stump  so  as  to  keep  the  loop  level  with 
the  parietes ;  it  is  open  to  yet  graver  objections.  As  a  rule, 
a  single  pin  is  not  sufficient.  The  process  of  transfixion  is  not 
always  easy,  and  requires  care  on  the  part  of  the  assistant  as 
well  as  the  operator.  The  guard  is  taken  off  the  point  of  the 
pin,  and  the  operator  enters  the  point  into  the  right  side  of  the 
pedicle  a  little  superiorly.  With  a  firm  thrust,  the  pin  is 
run  through  the  pedicle  till  its  point  emerges  on  the  left  side, 
towards  the  assistant,  who  must  guard  the  edge  of  the 
abdominal  wound  and  other  more  important  structiu'es  with 
a  sponge.  As  the  point  comes  out  of  the  tissues,  he  slips  his 
left  forefinger  under  it  and  guides  it  as  the  needle  is  pushed 
farther  by  the  operator  over  the  abdominal  integuments.  At 
the  same  time,  the  assistant  presses  the  edge  of  the  abdominal 
wound  against  the  pedicle.  When  the  pin  has  been  pushed  so 
far  as  to  project  equally  from  both  sides,  the  assistant  places 
the  guard  over  the  point.     The  operator  repeats  the  process  with 


296 


SUPRA- VAGINAL    HYSTERECTOMY. 


tlie  second  pin.  The  pins  should  he  entered  nearer  the  anterior 
and  posterior  houndaries  of  the  pedicle,  respectively,  than  the 
centre.  The  serre-noeud  {a  Fig.  118)  and  the  anterior  {c  c), 
and  posterior  [b  h)  pins  will  lie,  after  the  division  of  the 
pedicle,  as  indicated  in  the  accompanying  woodcut. 


Fig.  118. 


-The  Stump  of  the   Pedicle  of  a  Uterine   Fibroid  secured 

BY    KOEBERLE'S   SeRRE-NcEUD    .A.ND    TwO    SPECIAL    PiNS. 


Part  of  the  abdominal  wound,  with  the  sutures,  is  represented  above  the 
stump,  which  lies  in  the  lower  angle  of  that  wound.  Tlie  wire-loop,  which 
passes  behind  the  pins,  is  not  represented. 


The  passage  of  a  pin  is  sometimes  much  impeded  by  a  small, 
tough  interstitial  growth.  The  surgeon  must  take  care  not  to  push 
the  pin  to  the  least  extent  downwards,  else  the  point  may  strike 
against  the  wire  on  the  left  side,  or  even  emerge  on  the  cervical 
side  of  the  pedicle,  and  possibly  wound  an  important  structure. 
The  assistant's  duties,  as  indicated  above,  are  not  alwaj^s  easy, 
especially  when  he  has  to  support  a  very  heavy  tumoui'.  He 
is  liable  to  get  his  fingers  wounded  by  the  pin,  if  he  fails  to 


APPLICATION    OF    THE    PINS — DIVISION    OF    THE    PEDICLE.    297 

keep  tlie  abdominal  integuments  well  down  below  the  level  of 
the  constricting  wire  on  the  pedicle,  and  this  accident  not  only 
involves  pain  to  himself,  but  may  cause  him  to  let  go  of  the 
parts  suddenly,  so  that  the  surgeon  may  thrust  the  pin  into 
the  peritoneum  behind  the  wound,  or  even  into  the  intestine. 
Therefore  the  assistant  must  carefully  observe  where  the  point 
of  the  pin  issues  from  the  pedicle.  He  should  direct  the 
tumour  a  little  towards  the  operator  at  this  stage  of  the 
proceeding.  "When  the  tissue  of  the  pedicle  is  very  tough, 
the  operator  should  hold  the  head  of  the  pin  between  the 
jaws  of  the  pliers  employed  to  make  fast  the  wire  of  the 
serre-nceud. 

Division  of  the  Pedicle. — The  pins  being  in  place  (Fig. 
118),  the  wire  must  be  tightened  a  little  by  aid  of  the  key. 
The  tumour  is  now  cut  away.  There  will  be  great  bloodshed, 
but  it  will  be  from  the  tumour.  The  uterine  arteries  are  held 
secure  by  the  serre-nceud  (see  a  a,  Fig.  12).  The  surgeon 
takes  a  stout  scalpel  in  his  hand.  The  assistant  holds  a 
large  sponge  in  his  right  hand  and  supports  the  tumour  with 
his  left.  Then  the  tumour  is  cut  through  from  an  inch  and 
a  half  to  two  inches  above  the  pins,  by  a  semi-circular  sweep 
along  the  operator's  side,  and  another  carried  round  the 
opposite  side.  As  the  incisions  are  being  made,  the  assistant 
presses  the  sponge  against  the  cut  surface  of  the  tumour,  so 
as  to  keep  the  parts  from  being  concealed  by  blood,  but  the 
sponge  must  be  held  out  of  the  way  of  the  operator's  scalpel. 
Three  or  more  large  sponges  will  be  soaked  thi'ough  at  this 
stage.  Directly  the  tumour  is  cut  away  the  wire  of  the 
serre-noeucl  must  be  tightened.  The  tumour  is  di'opped  into 
a  pan  held  by  a  nurse  the  moment  that  the  pedicle  is  com- 
pletely divided.  Then  a  thorough  cleaning  of  all  the  parts 
around  the  pedicle  by  means  of  sponges,  and  a  good  washing 
of  the  hands  and  arms  of  the  operator  and  assistant,  will 
generally  be  necessary.  It  is  especially  advisable  that  all 
coagula  be  cleared  out  of  the  abdomen,  and  above  all  that 
the  space  between  the  lower  or  anterior  part  of  the  pedicle 
and  the  bladder  and  pubes,  including  the  lower  angle  of 
the  abdominal  wound  be  attended  to,  for  clots  are  very 
liable  to  collect  and  putrefy  there. 


29 S  SUPRA-YAGINAL    HYSTERECTOMY. 

Management  of  the   Stump   of  the   Pedicle. — The 

stimip  is  trimmed  down  until  just  sufficient  tissue  is  left  to 
prevent  the  pins  from  tearing  out.  Tliis  inaj'  be  done 
either  by  means  of  scissors,  or  by  a  scalpel  with  the  aid  of 
toothed  forceps.  Then  the  edges  are  stitched  across  from 
one  side  to  the  other.  Hagedorn's  needle  (page  116)  with 
No.  4  silk  is  very  convenient  for  this  pm-pose.  The  object 
is  to  make  the  stump  as  small  as  ^^ossible  and  to 
prevent  the  edges  from  becoming  everted  over  the  wound. 
In  the  case  of  a  very  thick  and  fleshy  stump  it  may  be 
desirable  to  dust  the  surface  lightly  with  iodoform,  by  aid 
of  a  Kabiersky's  insufflator  (page  138).  A  loop  of  stout 
silk  should  now  be  passed  round  the  upper  or  posterior  pin 
on  each  side,  and  the  ends  of  the  two  silks  are  given  to 
a  niu-se  or  second  assistant,  who  pulls  ui^on  them  so  as  to 
keep  the  pedicle  well  against  the  lower  angle  of  the  wound. 
This  is  done  by  standing  to  the  left  of  the  assistant,  close 
to  the  patient's  left  leg,  and  exercising  traction,  on  the  silks, 
downwards  towards  the  patient's  knees.  This  traction  should 
be  kept  up  till  the  abdominal  wound  is  closed  above  the  pedicle. 

The  wound  is  closed  as  in  ovariotomy,  Ijut  the  three  lowest 
sutiu^es  must  be  inserted  close  to  each  other,  not  more  than 
a  c^uarter  of  an  inch  apart,  so  as  to  give  mutual  support  at 
the  part  of  the  wound  where  the  traction  is  greatest.  The 
sutures  being  introduced,  the  peritoneal  cavity,  not  forgetting 
Douglas's  pouch,  is  cleaned  with  sponges,  and  the  sutures 
are  tied. 

A  pad  of  absorbent  gauze  is  now  placed  under  the  pins 
on  each  side  of  the  pedicle,  and  a  similar  dressing  under 
the  nozzle  of  the  serre-noeud.  Once  more,  the  wire  should 
be  gently  tightened.  Several  larger  folds  are  then  placed 
over  the  stump  and  the  upper  part  of  the  wound,  as  in 
ovariotomy.  A  large  pad  of  wool  is  then  placed  over  the 
whole  abdomen.  A  many-tailed  bandage  is  very  useful  to 
cover  in  the  dressings,  as  the  stump  must  be  frecjuently 
inspected,  and  a  bandage  of  this  kind  is  particularly  suitable 
for  that  purpose ;  it  involves  as  little  distm-bance  of  the 
dressings  as  possible.  The  directions  for  its  proper  appli- 
cation are  given  at  page  131. 


AFTER-TREATMENT.  299 

After  -  Treatment. — There  is  always  more  pain  after 
hysterectomy  than  after  an  ovariotomy  of  corresponding 
severity.  It  is  particularly  important  that  the  catheter  be 
used  frequently — that  is,  at  least  every  four  hours,  for  severe 
attacks  of  pain  often  come  on,  and  are  invariably  relieved 
more  or  less  completely  by  emptying  the  bladder.  Hence 
the  paramount  necessity  of  an  experienced  and  dexterous 
nurse  for  a  case  of  hysterectomy,  for  as  has  been  already 
observed,  in  speaking  of  the  after-treatment  in  ovariotomy, 
clumsy  eatheterism  is  certain  to  set  up  cystitis.  An 
inflamed  bladder  after  hysterectomy  causes  the  patient 
extreme  torment.  As  soon,  however,  as  she  can  do  so,  the 
patient  should  be  allowed  to  pass  water  without  the  aid  of 
oatheterism. 

The  stump  must  be  carefully  watched.  The  thicker  it  is 
the  greater  the  danger  of  heemorrhage,  especially  during  the 
first  twenty-four  hours,  and  bleeding  must  be  checked,  by 
tightening  the  serre-noeud  from  time  to  time,  not  only  for 
the  inherent  dangers  of  haemorrhage,  but  also  to  prevent 
the  stumj)  from  keeping  moist,  and  thereby  being  the  more 
exposed  to  sepsis.  A  careful  turn  of  the  screw  will  control 
the  bleeding.  The  raw  surface  should,  at  the  same  time, 
be  wiped  dry,  if  necessary,  with  wool  and  dusted  with  iodoform. 
The  stump  should  be  inspected  daily,  and  the  wire  made 
tight  whenever  desirable.  Within  two  or  three  weeks  the 
distal  part  of  the  stump  will  separate. 

Dm-ing  the  separation  of  the  stump,  its  tissues  must  be 
kept  very  dry,  and  should  be  gradually  cut  away.  When 
the  wire  is  removed,  the  pins  must  remain  on  for  a  few  days, 
and  the  surgeon  must  not  trim  the  tissues  too  freely  aroimd 
their  track,  for  the  great  danger  to  be  avoided  is  the  slipping 
back  of  the  proximal  end  of  the  stump  into  the  abdominal 
cavity  before  it  has  beguji  to  heal  by  granulation,  and  has 
become  quite  free  from  shreds  or  discharge.  When  the 
stump  does  slip  back  too  soon,  the  risk  of  septic  peritonitis 
is,  it  is  true,  very  slight,  as  the  parts  behind  the  stump  have 
generally  become  cut  off  from  the  peritoneal  cavity.  On 
the  other  hand,  troublesome  local  results  are  certain  to  ensue. 
The  wound  forms  a  deep  pit  with  the  stump  at  the  bottom, 


300  SUPRA-VAGIXAL    HYSTERECTOMY. 

and  the  process  of  healing  will  be  retarded  for  weeks — indeed, 
a  fistulous  track  may  remain  for  months. 

Convalescence  after  the  removal  of  a  uterine  fibroid  is 
never  quite  so  rapid  as  after  an  average  ovariotomy.  Grreat 
care  is  needed  to  keep  the  abdominal  walls  well  supported 
by  a  good  belt,  for  the  cicatrix  of  the  abdominal  wound  is 
very  apt  to  yield. 

The  general  treatment  after  hysterectomy  will  be  much 
the  same  as  after  ovariotomy.  The  upper  sutures  may  be 
removed  about  the  same  period,  and  the  bowels  should  be 
made  to  act,  for  the  first  time,  on  the  day  after  theii'  removal. 
The  lower  sutures,  especially  the  two  or  three  next  the 
pedicle,  should  be  left  as  long  as  possible.  Many  of  the 
complications  are  similar  to  those  which  may  follow  the 
removal  of  an  ovarian  cyst.  The  greatest  special  danger 
will  be  snapping  of  the  wire  and  haemorrhage  from  the 
stump.  This  must  be  guarded  against  by  the  employment 
of  a  stout,  soft  wire,  free  from  any  sharp  edges  due  to  bad 
finish,  and  not  worn  by  frequent  previous  use  ;  and  by  repeated 
inspections  of  the  stump.  When  the  wire  has  broken  it  can 
readily  be  taken  off  and  replaced ;  the  new  wire  must  be 
slipped  into  the  groove  formed  by  its  predecessor,  and  the 
free  end  made  fast  to  the  shank  of  the  button  (see  page  295) 
by  means  of  the  pliers.  This  involves  less  disturbance  of 
part  than  when  the  fingers  alone  are  used  for  the  pm-pose. 

Another  precaution  is  the  protection  of  the  structures 
around  the  lower  angle  of  the  wound  from  bruising  thi'ough 
pressure  of  the  end  of  the  serre-noeud  and  the  pins.  This 
is  avoided  by  keeping  a  stout  fold  of  lint  constantly  under- 
neath the  instrument  in  this  situation  and  also  under  the 
pins.  When  there  is  much  di-agging  on  the  pedicle, 
sloughing  of  some  of  the  integument  under  the  pins  is 
sometimes  unavoidable. 

Removal  of  Uterine  Fibroid  Outgrowths. — By  the 
term  "removal  of  a  fibroid  outgrowth,"  I  mean  the  amputation  of 
what  is  pathologically  known  as  a  pedunculated  subperitoneal 
fibro-myoma  of  the  uterus.  This  operation  should,  even  under 
the  most  favourable  circumstances,  be  considered  as  a  serious 
proceeding,  and  must  not  be  looked  upon  as  safer  and  easier 


REMOVAL    OF    UTERINE    FTBROII)    OUTGROWTHS.  301 

than  hysterectomy.  The  danger  of  wounding  the  bladder,  or  a 
ureter,  or  some  pelvic  structure,  may  be  absent,  and  the  uterine 
cavity  is  not  opened  up,  but  adhesions  very  difficult  to  separate 
are  frequent,  and  the  pedicle  may  be  so  thick  and  short  as  to 
baffle  any  attempt  to  secm-e  it,  in  the  literal  sense  of  the  word 
"  secure,"  so  that  either  the  entire  uterus  must  be  removed  or 
else  the  parts  must  be  left  untouched. 

A  group  of  small  spherical  fibroids,  feeling  like  a  pile  of 
round  cannon-balls  under  the  abdominal  integuments,  is  not 
suited  for  an  operation  of  this  kind.  The  outgrowths,  in  the 
first  place,  do  not,  in  themselves,  give  rise  to  much  pain  or  to 
hEemorrhage.  When  such  outgrowths  are  discovered,  in  a  case 
where  these  symptoms  exist,  they  should  not  be  removed  sepa- 
rately ;  either  the  entire  uterus  or  the  appendages  will  require 
removal.  Trifling  with  a  small  fibroid  is  a  great  mistake  ;  if  it 
be  thought  good  to  remove  it,  its  pedicle  must  at  least  be  trans- 
fixed with  No.  3  or  4  silk,  and  if  tough  it  had  better  be  secured 
with  the  serre-noeud.  If  simply  tied  within  a  single  sur- 
rounding loop,  the  pedicle  will,  almost  to  a  certainty,  slip  and 
place  the  patient  in  imminent  peril  from  htemorrhage. 

A  large  fibroid  outgrowth  may  weigh  ten,  twenty,  or  over 
twenty  pounds,  cause  grave  pressure  symptoms,  and  be  impos- 
sible to  diagnose  from  fibroid  disease  of  the  substance  of  the 
uterus,  until  the  abdominal  cavity  is  opened.  The  pedicle  may 
be  several  inches  long  and  shaped  like  a  leather  strap,  being 
made  of  tough  uterine  tissue,  or  it  may  be  very  short  and  per- 
fectly cylindrical,  or,  as  in  many  small  spherical  fibroids,  it  may 
be  chiefly  made  up  of  connective  tissue  with  large  vessels  and 
but  little  uterine  tissue. 

Ojjemtion.— The  surgeon  should  have  ready  all  the  instru- 
ments used  for  hysterectomy,  including  the  pins  as  well  as  the 
clamp.  The  fibroid  is  drawn  out  of  the  abdominal  wound; 
sometimes  its  true  natm-e  can  only  be  detected  when  this  has 
been  done.  Having,  therefore,  made  sm-e  that  it  is  an  out- 
growth, and  not  a  mass  forming  part  of  the  uterus  itself,  its 
pedicle  must  be  carefully  examined. 

In  the  first  place,  however,  adhesions  may  have  to  be 
separated.  I  have  seen,  in  some  of  Dr.  Bantock's  cases  of 
uterine     fibroid     outgrowths,    the    worst    forms    of     omental 


302  OPERATIOXS    ON    FIBROID    TUMOURS    AND    POLYPI. 

adliesions.  In  one  instance,  where  the  fibroid  weighed  twenty- 
five  pounds,  not  only  were  the  omental  vessels  as  large  as 
they  often  are  in  cases  of  fibroid  uterus,  but  the  lymphatics 
were  dilated  to  the  caHbre  of  a  crowquill.  The  surgeon  must 
remember  that  a  ureter  may  get  lodged  in  a  groove  between 
the  fibroid  and  the  body  of  the  uterus,  where  it  may  become 
adherent  to  the  uterine  or  tumour-tissues  and  he  in  danger 
of  injury  during  operation. 

I  have  generally  found  the  pedicle  to  be  under  two  inches 
long,  subeyhndrical,  and  springing  from  the  uterus  close  behind 
the  fundus.  I  have,  however,  seen  a  very  long,  flat,  strap-like 
pedicle.  The  surgeon  had  better  make  it  a  rule,  provided  that 
he  thinks  it  proper  to  remove  the  fibroid  alone,  to  secure  the 
pedicle  by  the  wire  of  a  Koeberle's  clamp,  and  then  to  pass  one 
pin,  or  two  pins  if  the  pedicle  be  broad  and  cylindrical,  through 
it  on  the  distal  side  of  the  wire,  finally  cutting  it  through 
beyond  the  pin.  In  fact,  the  pedicle  is  treated  exactly  as  if  it 
were  the  stump  of  the  uterus  after  hysterectomy. 

Transfixion  and  ligature  is  very  unsafe,  even  for  a  strap-like 
pedicle  as  in  Fig.  119.  The  contractile  power  of  a  pedicle  of 
this  kind,  made  up  as  it  is  of  plain  muscular  fibres,  is  extra- 
ordinary ;  if  the  ligature  slips,  the  stump  appears  as  a  wide 
surface,  bleeding  actively,  and  but  little,  if  at  all,  raised  above 
the  level  of  the  surrounding  uterine  tissue.  This  property  of 
the  pedicle  is  best  seen  dming  hysterectomy  when  a  small 
fibroid  gets  torn  off  before  the  wire  of  the  serre-noeud  is  made 
fu'm.  In  January,  1886,  I  assisted  Dr.  Bantock  at  an  operation 
for  the  removal  of  a  fibroid  from  a  woman  aged  thhty-four. 
The  tumour  formed  a  large  movable  mass  in  the  abdomen  and 
caused  great  trouble  from  pressiu-e.  On  opening  the  abdomen 
it  was  found  to  be  a  large  spherical  fibroid,  connected  with 
the  left  side  of  the  fundus  of  the  uterus  by  a  strap-like  pedicle 
about  an  inch  long  when  unstretched.  It  was  transfixed 
with  No.  4  silk  ligatm^ed,  and  divided.  In  a  few  minutes  the 
central  part  of  the  cut  surface  began  to  cup,  the  Hgatm-e 
simidtaneously  loosening.  Another  was  applied,  by  transfixion 
as  before,  but  it  was  found  untrustworthy,  so  a  Koeberle's 
serre-noeud  was  used,  and  a  single  pin  passed  through  the  pedicle. 
The  patient  made  a  very  good  recovery.     In  four  more  cases 


REMOA'AL    OF    UTERINE    FIBROID    OUTGROWTHS. 


303 


wliere  I  assisted  the  same  surgeon,  in  1886,  the  serre-noeucl 
proved  to  be  indispensable.  In  the  case  already  noted  where  the 
fibroid  outgrowth  weighed  twenty-five  pounds,  the  pedicle  was 
perfectly  cylindrical  and  nearly  three  inches  in  diameter.  It 
sprang  from  behind  the  right  angle  of  the  fundus  and  was  very 
difficidt  to  seciu'e,  requiring  two  pins  as  well  as  the  serre-nceud. 
The  patient  recovered.  It  frequently  happens  that  disease  of 
the  appendages  exists  in  association  with  large  fibroids,  so  that 


Fig.  119. — Uterus  with  Large  Fibroid  Oftgrowth. 

The  pedicle  measured  over  four  inches  iu  length  before  the  parts  were  taken 
out  of  the  body.  The  patient  died  after  abortion  at  the  fourth  month. 
(3fuseur,i  R.C.S.,   No.  4,639.) 

oophorectom}'  is  needed,  and  this  cannot  be  safely  done,  in 
many  cases,  without  hysterectomy  as  well.  Such  cases  are 
amongst  the  most  difficult  and  dangerous  in  abdominal 
surgery,  and  should  never  be  performed  excepting  when  intract- 
able chronic  haemorrhage  and  distressing  symptoms  exist. 

Excision  of  Fibroid  Polypi. — It  is  quite  comprehensible 
that  the  surgeon  should  feel  read}^  to  cut  away  a  solid  yet  well- 


304  OPERATIONS    ON    FIBROID    TUMOURS    AND    POLYPI. 

pedunculated  mass,  which  he  has  detected  protruding  fi-eely 
into  the  vagina.  He  is  right  to  advise  operation,  and  in  cases 
where  there  is  marked  menorrhagia,  or,  more  correctly  speaking, 
metrostaxis,  it  is  his  duty  to  urge  operative  interference  as  soon 
as  possible.  At  the  same  time,  he  must  never  treat  the  ease  as 
a  "minor"  operation.  It  must  be  done  in  the  operating 
theatre,  or  in  the  patient's  room,  like  an  amputation  or  a 
lithotomy,  and  the  patient  must  be  kept  in  bed  for  a  day  or 
two,  her  pulse  and  temperatm-e  taken  regularly,  and  her  vagina 
kept  clean  by  frequent  injections. 

It  is  very  questionable  whether  even  a  small  fibroid  polypus 
should  be  snipped  off  in  the  out-patient  room  of  a  hospital. 
Such  a  proceeding  puts  the  patient  to  a  certain,  even  if  remote, 
risk,  and  the  operation  is  essentially  different  from  other  active 
measures  sometimes  justifiable  in  the  out-patient  room,  such  as 
opening  an  abscess  which  gives  pain  or  thi-eatens  to  bm-row, 
or  making  incisions  in  an  inflamed  hand  to  save  tendons  from 
sloughing.  In  such  proceedings,  the  pathological  conditions 
are  rendered  less  serious  than  before  the  surgeon's  interference. 
After  snipping  or  crushing  the  tough  pedicle  of  a  fibroid 
polypus,  the  patient  goes  home  with  an  open  bleeding  sui-face* 
in  the  uterus  freely  bathed  with  its  discharges.  For  the  tissue 
of  the  pedicle  retracts  to  an  extreme  extent  after  division,  so 
that  its  site  is  marked  not  by  a  projecting  stump,  but  by  a  raw 
surface  or  even  a  distinct  depression. 

Dr.  Matthews  Duncan,  the  most  cautious  of  contemporary 
authorities,  speaks  of  a  fatal  case,  which,  it  must  be  noted,  took 
place  in  a  hospital  ward.  "  The  case  was  a  simple  one,  a 
common  fibrous  polypus  of  the  size  of  an  apple,  and  a  stalk  as 
thick  as  your  little  finger.  It  was  removed  easily  by  volsella 
and  scissors.  In  a  few  days  the  patient  was  dead.  A  post- 
mortem examination  was  made  and  nothing  pecuhar  was  found. 
The  little  wound  near  the  os  uteri  seemed  c^uite  healthy.  In 
no  other  case  have  I  had  even  alarm." 

The  patient  will  not  recj^uire  an  anfesthetic  when  the  pol}']^Jus 

*  There  is  generally  little  h;eraorrliage,  it  is  true,  after  division  of  the  pedicle, 
owing  to  retraction  of  the  proximal  end.  But  vessels  which  cease  to  bleed  do 
not  at  once  cease  to  absorb  through  their  open  ends,  and  the  thrombi  which  close 
them  may  be  the  source  of  a  worse  peril  than  the  hajmon'hage  which  they  check. 


EXCISION    OF    A    FIBROID    POLYPUS.  305 

is  small  and  its  pedicle  readily  accessible  on  digital  examination 
tkrough  the  vagina.  In  such  a  case  the  vagina  is  simply 
washed  ont,  and  the  patient  laid  on  her  left  side.  The  surgeon 
seizes  the  polypus  with  a  volsella  or  speculum-forceps,  held  in 
his  left  hand,  and  then  draws  it  well  down,  so  as  to  get  the 
pedicle  in  sight.  The  pedicle  is  then  divided  with  scissors 
curved  on  the  flat.  The  vagina  should  be  syringed  out  once 
more,  with  a  weak  iodine  or  carbolic  solution,  and  the  patient 
is  put  to  bed  for  twenty-four  hours.  The  vagina  must,  of 
course,  be  kept  thoroughly  clean  by  injections  for  a  few  days. 

When  the  fibroid  is  large  and  likely  to  give  trouble  during 
manipulation,  an  anaesthetic  must  be  administered.  This  will 
facilitate  thorough  exploration,  so  that  the  existence  of  other 
polypi  or  of  partial  inversion  of  the  uterus  may  be  ascertained. 
The  patient  should  be  placed  in  lithotomy  position,  and  when 
she  is  well  under  the  influence  of  the  anaesthetic,  the  finger 
must  be  passed  round  the  pedicle.  Its  insertion,  as  well  as  the 
position  of  the  fundus  uteri,  is  then  determined.  Sometimes 
the  finger  cannot  reach  the  pedicle,  then  its  thickness  may 
be  estimated  by  a  sound,  or  by  the  ease  with  which  the 
tumour  can  be  rotated  when  grasped  by  forceps,  as  Berry 
Hart  suggests. 

It  may  happen  that  the  polypus  is  so  large  as  to  require 
reduction  in  size  before  it  can  be  pulled  out  of  the  vagina. 
A  wedge-shaped  piece  may  be  cut  out,  or  Hegar's  spiral 
incision  practised.  The  accessible  part  of  the  tumour  is 
grasped  with  a  strong  volsella,  which  the  surgeon  holds  in 
his  left  hand.  He  takes  in  his  right  hand  a  strong  pair  of 
scissors  curved  on  the  flat,  and  then  cuts  deeply  and  obliquely 
into  the  tumour.  The  incision  is  continued  upwards,  as  the 
tumour  is  rotated  and  pulled  down  with  the  volsella.  In  this 
way  a  long  flap  is  gradually  dragged  out  by  the  forceps,  and 
at  length  the  pedicle  can  be  reached.  This  ingenious  method 
is  preferable  to  the  use  of  midwifery-forceps,  or  to  cutting  open 
the  perineum,  yet  resort  to  the  latter  extreme  measure  is 
sometimes  necessary.  It  not  unfrequently  happens,  esj)ecially 
in  the  case  of  large  polypi  of  long  standing,  with  their  nutri- 
tion impaired  by  pressm^e  of  the  walls  of  the  uterus  on  the 
pedicle,  that  the  substance  of  the  tumour  is  very  brittle  and 

X 


306  OPEKATIOXS    ON    FIBROID    TUMOUES    AND    POLYPI. 

tears  awaj'  when  traction  with,  the  volsella  is  attempted.  This 
makes  the  operation  long  and  tedious,  and  much  blood  may  be 
lost  until  the  pedicle  is  divided. 

The  pedicle  being  reached,  if  very  thin,  it  can  be  twisted  off, 
by  simple  rotation  of  the  volsella.  If  tolerably  thick,  the 
surgeon  should  entrust  the  forceps  to  his  assistant,  who  keeps 
the  tumoiu'  well  drawn  do"UTi.  Then  the  operator  takes  a 
pair  of  scissors  curved  on  the  fiat  in  his  right  hand,  and 
guarding  the  uterus  by  passing  two  fingers  of  the  left  hand  in 
front  of  the  scissors,  he  cuts  through  the  pedicle.  If  the  pedicle 
be  very  thick  a  wire  ecraseur  may  be  used,  but  even  a  thick 
pedicle  may  be  di^dded  by  the  scissors  with  little  risk  of 
haemorrhage.  The  stump  of  the  pedicle  retracts,  and  is,  in 
fact,  lost.  The  vagina  must  be  well  washed  out  before  the 
patient  is  put  to  bed. 

The  patient,  after  the  operation,  should  remain  in  bed  for  a 
few  days,  and  the  vagina  should  be  kept  clean  with  injections. 
Owang  to  the  contractility  of  the  pedicle,  htemoiThage  is  even 
more  rare  diuing  recovery  than  on  the  operating  table. 

Ligatiu'e  of  Fibroid  Polypi. — The  strangulation  of  the 
pedicle  of  a  fibroid  polj'pus  by  ligatiu-e  should  never  be 
attempted.  Experience  has  shoTsm  that  the  sloughing  of  the 
tumour  often  causes  septic  changes.  This  proceeding,  once 
very  popular,  is  only  mentioned  to  be  condemned. 

Removal  of  Fibroid  Polypi  by  the  Ecraseur. — Some 
authorities  still  prefer  the  ecraseur  to  the  scissors.  Dr.  Matthews 
Duncan  declares  that  haemorrhage  is  in  reahty  very  rare  when 
the  scissors  are  used.  Should  the  ecraseui'  be  preferred  it  must 
be  stout  in  the  stem,  and  a  single  strong  wire,  or  a  rope  made 
by  twisting  several  strong  wii-es,  will  be  needed,  according  to 
circumstances.  The  application  of  the  noose  may  be  difficult  if 
the  pedicle  be  short.  The  vagina  must  be  syringed  out  before  the 
operation,  and  an  anaesthetic  is  not  advisable,  for,  as  Dr.  Gralabin 
has  pointed  out,  the  di\dsion  of  the  pedicle  gives  Httle  or  no 
pain,  while  pain  is  severe  if  the  uterine  wall  be  included  in  the 
loop,  and  thus  an  error  may  be  revealed  in  time,  when  the 
patient  is  not  imder  chloroform.  Of  course  the  volsella  or  a 
tenaculum  Mill  be  useful  in  drawing  down  the  polypus,  so  that 
the  loop  of  wire  may  be  passed  round  the  pedicle. 


ENUCLEATION    OF    FIBKOID    GROWTHS.  307 

Enucleation  of  Fibroid  Growths.* — This  operation  is 
an  imitation  and  anticipation  of  a  natural  process.  The 
sloughing  of  the  capsule  of  a  submucous  fibroid  and  its  delivery 
through  the  vagina  is  a  phenomenon  long  known  in  the  history 
of  medicine,  but  nature  unassisted  may  fail  to  cure,  the  patient 
succumbing  to  pain  or  to  septic  changes  in  the  sloughy  tumour. 

When  the  fibroid  tumour  has  distended  the  os,  its  artificial 
enucleation  is  perfectly  justifiable,  according  to  modern  ideas. 
On  the  other  hand,  to  seek  a  fibroid  in  the  iiterine  cavity  after 
dilatation  of  the  os  by  means  of  tents,  to  cut  through  the 
capsule  and  then  to  shell  out  the  tumour,  is  a  difficult  and 
hazardous  proceeding.  Experience  has  proved  the  dangers 
which  theory  could  foresee.  The  operation  was  frequent  before 
oophorectomy  and  supra- vaginal  hysterectomy  were  performed, 
but  it  is  jDrobably  far  more  perilous  than  those  proceedings. 
When  a  fibroid  growth  bulges  evenly,  as  far  as  bimanual 
palpation  can  prove,  towards  the  uterine  cavity  and  towards  the 
peritoneum,  its  capsule  may  be  very  thin  on  the  peritoneal  side 
so  as  to  be  in  great  danger  of  laceration  when  the  tumour  is 
shelled  oiit.  Therefore,  instead  of  attempting  enucleation,  it 
must  either  be  left  alone,  or  one  of  the  abdominal  operations 
just  named  should  be  performed. 

The  case  is  otherwise  when  the  fibroid  presents  at  the  os 
uteri,  or  lies  more  or  less  in  the  vagina,  especially  should  the 
capsule  be  sloughy  or  deeply  congested,  whilst  bimanual 
examination  of  the  uterus  gives  fair  reason  to  suppose  that 
there  are  no  other  large  fibroid  growths  besides  that  which 
is  being  slowly  delivered.  To  enucleate  is  then  only  to  assist 
nature,  and  it  is  hard  to  see  why  the  dangers  of  abdominal 
section  should  be  inciu-red  under  the  circumstances. 

The  Operation  of  Enucleation. — I  put  aside  all  cases 
where  the  fibroid  tumoiu-  is  not  presenting  at  the  os,  and  where 
dilators  would  be  needed,  and  will  confine  myself  to  cases  where 
the  tumour  has  commenced  to  protrude  through  the  os.  The 
patient's  bowels  must  be  thoroughly  cleared  in  the  way  recom- 

*  "An  mtra-uterine  growth,  not  intra-cervical,  is  either  sessile  or  has  only  a 
neck  ;  it  has  no  distinct  stalk  to  make  it  a  polji^us."  (Matthews  Duncan,  Clinical 
Lectures  on  the  Diseases  of  Women,  Third  edition,  Lecture  xxxiv.)  He  admits 
that  little  mucous  intra-uterine  polypi  may  be  pedunculated. 


308  OPEKATIONS    ON    FIBROID    TUMOURS    AND    POLYPI. 

mended  in  the  chapters  on  Ovariotomy,  for  an  action  of  the 
bowels  dm'ing  the  operation  is  an  intolerable  hindrance  to  the 
surgeon.  The  patient  should  be  placed  on  her  back  in  lithotomy 
position,  and  a  Clover's  crutch  (page  132)  placed  between  her 
knees  to  keep  them  apart.  This  arrangement  is  better  than 
entrusting  an  assistant  to  hold  the  lower  extremities  in  the 
correct  position,  as  it  economizes  labour  in  an  operation  where 
many  helping  hands  may  be  needed.  Some  surgeons  prefer 
to  place  the  patient  on  the  left  side. 

The  patient  is  anaesthetized,  and,  when  the  tumour  is  not  so 
far  delivered  as  to  present  at  and  block  the  vulva,*  a  Sims' 
speculum  is  now  passed  along  the  posterior  wall  of  the  vagina, 
until  it  exposes  the  projecting  part  of  the  tumour.  The  siu-geon 
should  carefully  explore  the  pelvic  viscera,  especially  if  he  has 
not  examined  the  patient  before  under  chloroform.  Having 
made  sure  of  his  diagnosis,  particularly  as  regards  the  relation 
of  the  margin  of  the  os  to  the  tumour,  he  directs  his  assistant 
to  push  the  fundus  of  the  uterus  well  downwards  by  firm  pressure 
through^the  integuments  of  the  hypogastrium.  Sometimes  it  can 
be  pressed  down  so  low  that  the  speculum  is  no  longer  necessary. 

The  surgeon  then  makes  a  deep  incision  in  the  exposed  part 
of  the  capsule.  This  incision  should  be  transverse  if  he  can 
safely  cut  for  about  an  inch  and  see  his  incision  all  the  way, 
crucial  if  he  cannot  cut  fai^  enough  in  one  direction  without 
getting  the  point  of  his  scalpel  out  off  sight.  He  next  begins 
to  peel  the  capsule  off  the  fibroid.  The  cut  edges  of  the  capsule 
should  be  seized  with  stout  pressure-forceps  and  held  apart  by 
assistants.  The  operator  must  endeavoui*  to  peel  off  the  capsule 
with  his  forefinger,  and  the  more  he  can  dispense  with  instru- 
ments the  better.  He  first  grasps  the  exposed  part  of  the 
tumour  with  a  strong  volsella.  The  light  puny  instrument 
used  for  pulling  the  ovarian  cyst-wall  under  the  teeth  of  the 
trocar  in  ovariotomy  is  quite  useless  for  this  purpose,  and  will 
probably  be  spoilt  if   so    employed.     Kidd's   strong   volsellat 

*  When  this  is  the  case  it  does  not  follow  that  the  operation  will  be  short  and 
easy,  for  the  widest  i)art  of  the  tumour  is  not  necessarily  in  sight.  The  most  bulky 
and  wider  part  may  still  be  in  the  uterine  cavity,  perhaps  above  the  pelvic  brim. 

t  Sir  James  Simpson's  volsella  for  intra-uterine  fibroids  is  also  very  useful. 
The  ojierator  should  prefer  the  longest  handled  instrument  of  this  kind  which  he 
linds  available.     A  short  forceps  is  highly  inconveiiient. 


ENUCLEATION    OF    FIBROID    GROWTHS. 


309 


(Fig.  120)  will  be  found  very  serviceable.  The  handles  are 
pulled  open  by  the  left  hand  of  the  operator,  so  that  he  can 
draw  the  tumour  towards  him  with  a  sHght  rotatory  move- 
ment, and  extract  it  steadily  as  his  right  forefinger  detaches 
it  from  its  capsule. 

So   great   is   the   difficulty    sometimes    experienced    at   this 
stage,    that   many   instruments    have   been    devised  to    assist 


Fig.  120. — Kidd's  Yolsella. 

in  the  process  of  detaching  the  capsule.  Of  these  instru- 
ments it  may  be  affirmed  that  none  can,  to  say  the  least,  be 
safely  used  unless  the  operator  has  frequently  seen  them 
employed  by  experts.  The  late  Dr.  Thorburn  recommended 
a  strong  steel  male  sound  and  a  blunt- edged  lithotomy 
scoop  as  the  safest  aids  to  the  surgeon's  forefinger.  They 
can  be  swept  over  the  tumour  along  lines  of  adhesion  to 
the   capsule.     There  is  a  formidable   instrument — famiKar  to 


Fig.  121. — Sims'  Guarded  Tumour-Hook. 

many  only  as  an  ornament  in  instrument-makers'  windows, 
called  Sims'  guarded  tumour-hook  (Fig.  121),  which  is  useful 
in  pulling  down  a  large  mass  of  detached  fibroid.  The 
piece  of  black  wood  is  pulled  up  towards  the  handle,  then 
the  left  forefinger  is  slipped  over  the  convex  sm^face  of  the 
fibroid  till  it  reaches  the  part  still  imdetached  from  the  cap- 
sule ;  into  the  substance  of  the  tumour  just  below  that  part 
the  prongs  of  the  instrument  are  thrust,  then  the  piece  of 
wood  is  pushed  against  the  lower  point  of   the  fibroid.     The 


310  OPERATTOXS    ON    FIBROID    TUMOL'RS    AND    POLYPI. 

surgeon  can  then  pull  hard  on  the  tumour-hook  till  the 
unenucleated  part  of  the  fibroid  is  brought  within  reach  of 
his  forefinger.  The  mechanism  of  the  instrmnent  protects 
surrounding  structures  from  injury  from  the  prongs,  which 
become  guarded  by  the  piece  of  wood  directly  they  tear  away 
from  their  attachments.  Still,  this  tumour-hook  requires 
careful  adjustment,  and  is  never  indispensable. 

When,  indeed,  the  tumour  is  very  large  and  hard  to  dehver, 
it  is  best  to  cut  it  in  pieces  by  means  of  scissors.  One  side 
of  the  exposed  part  must  be  cut  from  below  upwards,  then 
more  of  the  tumom*  can  be  pulled  doT\Ti  by  aid  of  the  strong 
volsella.  As  the  uppermost  part  comes  v.dthin  the  operator's 
reach,  he  must  see  that  he  does  not  invert  the  uterus  by 
pulhng  too  hard,  and  that  the  assistant  does  not  cause  the 
same  accident  by  pushing  too  forcibly  on  the  fundus.  Inver- 
sion has  repeatedly  occmTcd  dm'ing  enucleation,  even  in  the 
experience  of  cautious  and  skilful  operators,  and  sometimes 
wath  fatal  results. 


Fig.  122. — Sims'  Tampox-Sckew  oe.  Fixateur. 

The  oj)erator  must  beware  of  and  examine  every  mass 
that  comes  down  either  slowly  or  suddenly  in  the  course 
of  the  operation,  and  must  bear  in  mind  that  an  inverted 
uterus  is  not  always  to  be  distinguished  at  a  glance. 
When  the  uterus  is  unfortunately  inverted,  it  should  be  care- 
fully washed  with  solution  of  iodine,  and  retm'ned  after  the 
attachment  of  the  tumour  has  been  cut  away.  A  few  wool- 
plugs,  each  attached  to  a  piece  of  string,  and  soaked  in 
tincture  of  iodine,  may  be  inserted  into  the  uterine  cavity, 
and  carefully  removed  two  or  three  days  afterwards  piece 
by  piece.  When  thus  extracted,  it  is  not  ad^asable  to  pull 
at  all  the  strings  at  once,  nor  is  it  easy  to  find  out  which 
string  belongs  to  the  plug  nearest  to  the  os — to  that,  in 
fact,  which  should  be  pulled  out  first.  Extraction  is  best 
effected  by  means  of  an  instrument  known  as  Sims'  screw 
(Fig.  122). 

It   consists  of  a  slender   steel  bar  five  or  six  inches  long. 


ENUCLEATION    OF    FIBROID    GROWTHS.  311 

and  mounted  on  a  wooden  handle.  At  the  point  is  a  fine 
screw.  The  bar  being  introduced  like  a  sound,  the  point  is 
guided  to  the  os  and  pressed  against  the  wool.  By  gently 
rotating  the  instrument  on  its  long  axis  the  screw  soon  gets 
entangled  in  the  wool,  then  the  first  plug  can  be  drav^-n 
out.  The  other  plugs  are  successively  removed  in  the  same 
manner,  though  the  last  can,  as  a  rule,  be  safely  drawn 
out  by  its  string.  The  instrument  saves  the  operator  from 
the  risk  of  inverting  the  uterus  once  more,  during  traction 
on  the  strings. 

There  is  yet  another  danger  besetting  this  operation,  even 
more  serious  than  inversion  of  the  fundus  or  of  the  entire 
uterus.  In  drawing  down  a  fibroid  which  has  a  broad 
attachment  to  the  inner  wall  of  the  uterus,  especially  when 
it  projects  from  near  the  cervix  posteriorly,  the  portion  of 
the  wall  whence  it  springs  may  become  inverted.  As  the 
line  of  junction  between  the  tumour  and  the  uterine  wall 
is  difiicult  to  define,  the  operator  may,  in  such  a  case,  cut 
through  the  latter,  laying  open  the  peritoneal  cavity. 

After  the  fibroid  has  been  completely  enucleated,  the 
uppermost  part  of  the  capsule,  kept  well  in  sight,  should 
be  freely  washed — first  with  water,  then  with  tincture  of 
iodine, — and  then  the  entire  capsule,  which  will  be  greatly 
shrunken,  must  be  plugged  with  pledgets  of  wool  soaked  in 
iodine.  The  vagina  is  next  plugged  in  the  same  manner  ;  the 
external  parts  are  then  cleaned,  and  the  patient  is  put  to  bed. 

The  plugs  may  be  left  in  place  for  about  forty-eight 
hours,  but  in  the  meantime  the  patient  must  be  carefully 
watched,  and  the  pulse  and  temperature  taken  at  regular 
intervals  of  four  or  six  hours,  lest  haemorrhage  or  septic 
infection  should  arise.  When  signs  of  the  former  appear, 
which  is,  fortunately,  very  unusual,  the  plugs  must  be 
removed,  together  with  any  clots  or  collection  of  fiuid  blood 
that  may  be  discovered,  and  after  a  thorough  cleaning  with 
a  weak  iodine  solution  (about  a  clrachm  of  the  tincture  to 
a  pint  of  tepid  water)  the  plugging  must  be  rej^eated.  When 
the  temperature  and  pulse  rise  high,  and  remain  so  for 
several  hours,  the  vagina  should  be  explored  in  the  same 
manner,  but  a  stronger  solution  of  iodine  should  be  used. 


312  OPERATIONS    ON    FIBROID    TUMOURS    AND    POLYPI. 

Wlien  all  goes  well,  aliening  for  a  rise  of  temperature 
to  about  100',  and  for  various  relatively  mild  forms  of  con- 
stitutional disturbance  due  to  shock  and  the  ansestheties, 
the  plugs  should  be  carefully  removed  on  the  second  day, 
and  the  state  of  the  parts  explored  with  the  aid  of  a  Sims' 
speculum.  Eagged  shreds  of  tissue  should  be  cut  away,  and 
if  any  part  of  the  interior  of  the  capsule  be  still  exposed, 
it  may  be  touched  mth  tinctm^e  of  iodine,  apphed  on  wool 
mounted  on  a  sponge-holder.  If  all  signs  of  haemorrhage 
have  ceased,  as  is  almost  invariably  the  case,  the  plugging 
need  not  be  repeated,  and  the  vagina  should  be  well  washed 
out  "nith  weak  iodine  solution  night  and  morning  until  all 
discharge  has  ceased.  The  speculum  must  be  used  occasion- 
ally for  inspection  of  the  cervix  and  the  os.  I  admit 
that,  owing  to  the  natui'e  of  the  capsule,  hsemorrhage  is 
rare  after  enucleation,  and  septicaemia  is  not  very  common, 
but  botli  have  occuiTed,  and  the  sm'geon  can  never  be  too 
careful  about  after-treatment  in  operations  performed  in  the 
region  of  the  uterine  cavity  and  the  vagina. 

Incision  of  the  Capsule. — T\Tien  a  fibroid  is  presenting 
at  the  OS  externum,  and  is  evidently  in  process  of  expulsion, 
when  that  process  is  progressing  slowly  but  steadily,  and  is 
influenced  by  the  administration  of  ergot,  it  is  sometimes 
sufficient  to  incise  the  capside  so  as  to  hasten  the  expulsion 
of  the  tmnom'  -without  incuiTing  the  difficulties  and  dangers 
of  artificial  enucleation.  Experienced  specialists  sometimes 
incise  the  capsule  before  the  tumour  has  passed  out  of  the 
uterine  cavity;  they  fii'st  dilate  the  cervix  by  means  of 
tents  or  hydrostatic  bags.  I  have,  however,  already  noted 
the  dangers  of  an  operation  of  this  kind. 

It  is  best  to  employ  the  cautery  for  incising  the  capsule. 
When  Paquelin's  thermo-cautery  is  used,  a  point  of  suitable 
size  is  heated,  and  an  incision  about  one  inch  long  is  burnt 
through  the  capsule.  The  point  should  be  made  to  penetrate 
the  capsule  to  the  extent  of  a  quarter  of  an  inch,  or  even 
deeper.      It  matters  little  if  the  tumom-  be  burnt.* 

"WTien  the  galvano-cautery  is  needed  for  incising  the  capsule, 

*  Burning  the  tissues  of  the  tumour  itself  has  been  practised  systematically 
and  successfullv  bv  Dr.  Greenhalgh  and  others. 


INCISION    OF    CAPSULE — REMOVAL    OF    MUCOI'S    POLYPUS.       313 

a  firm  platinum  knife  (Fig.  69)  is  used.  It  is  applied  h.ot  to 
the  sm-face  of  the  capsule,  with  a  kind  of  sliding  or  cutting 
movement,  till  a  bm-n  of  about  an  inch  in  length  is  thus 
made  through  the  capsule.  It  does  not  matter  if  the  tumour 
itself  be  also  burnt.  After  the  tumoiu-  has  been  exposed 
by  burning  tlirough  its  coverings,  its  further  attachment  to 
the  capsule  should  be  broken  down,  by  means  of  the  fingers, 
as  far  round  as  is  possible  until  the  part  is  reached  where 
the  growth  is  attached  to  the  wall  of  the  uterus.  If  this 
attachment  be  sufficiently  pedunculated,  the  operation  may 
be  completed  at  once  by  passing  the  platinum  wire  of  a 
galvanic  ecraseur  (Figs.  70,  71)  over  the  tumour,  tightening 
it  round  the  neck,  and  then  allowing  the  wire  to  huin 
through  after  the  circuit  is  closed,  in  the  same  way  as  when 
a  cancerous  cervix  uteri  is  amputated,  an  operation  which 
will  be  described  in  the  next  chapter. 

If  the  base  of  the  tumour  be  very  broad,  ergot  should 
be  given  to  increase  the  expulsive  action  of  the  uterus, 
which  is  already  present,  or  has  been  set  up  by  the  dilata- 
tion of  the  OS  and  rupture  of  the  capsule  of  the  tumour.  By 
this  means,  the  tumour  becomes  gradually  elongated,  and 
may  be  extruded  through  the  os  externum.  It  sometimes 
almost  blocks  up  the  vagina.  About  the  end  of  a  fortnight, 
an  attempt  may  again  be  made  to  remove  the  tumour  by 
the  galvanic  ecraseur,  or,  at  least,  part  of  it  may  be  removed  in 
this  way,  especially  any  portion  that  may  have  become  sloughy; 
and  again,  at  a  subsequent  operation,  the  remaining  part 
of  the  tumom-  may  possibly  be  removed.  The  risk  of  septic 
poisoning  in  all  operations  about  the  vagina  and  uterus  should 
constantly  be  borne  in  mind,  and  antiseptic  ii-rigation  fre- 
quently practised  both  during  the  extrusion  of  the  fibroid 
and  after  its  ultimate  removal.  For  this  purpose,  a  solution 
of  corrosive  sublimate  (1  in  2,000)  may  occasionally  be  used,, 
but  more  frequent  irrigations  should  be  practised  ^-ith  car- 
bolic acid  solution  (1  in  80),  or  tincture  of  iodine  diluted  with 
one  or  two  parts  of  water. 

Removal  of  a  Mucous  Polypus. — The  vagina  must 
fijst  be  well  washed  with  some  weak  antiseptic  solution,  such 
as  carbolic  acid  1  in  40,  sulphurous  acid  1  in  10,  or  twenty 


314 


OPERATIONS   ON    FIBROID    TUMOURS   AND    POLYPI. 


minims  of  tincture  of  iodine  to  tlie  pint  of  water.  The 
cervical  canal  should  then  be  cleaned  by  pledgets  of  wool 
introduced  by  means  of  a  speculum-forceps.  The  wool,  after 
the  mucus  has  been  wiped  away,  must  be  dipped  in  the  anti- 
septic solution.  These  preliminary  precautions  must  never  be 
omitted.  A  Fergusson's  speculum  will  answer  very  well  for 
the  cleaning  of  the  cervical  canal  and  for  the  operation,  the 
patient  lying  on  her  left  side.  If,  however,  there  be  difficulty 
in  bringing  the  cervix  and  the  polypus  into  view,  a  Sims'  or 
Neugebauer's  speculum  is  preferable,  and  the  j^atient  should 
be  placed  in  lithotomy  position. 

A  uterine  polypus-forceps  (Fig.  123)  will  be  necessary  for  the 
removal  of  the  growth.  It  is  of  considerable  length,  and  has  a 
catch,  so  that  the  handles  can  be  fixed  whilst  the  polypus  is 


Fig.  123. — Uterine  Polypus-Forceps. 


being  twisted  ;  without  a  catch,  the  process  becomes  clumsy,  and 
the  teeth  of  the  forceps  may  slip  off  the  polypus  before  com- 
plete avulsion.  It  does  not  matter  whether  the  catch  be  placed 
on  the  shanks  a  little  above  the  bows,  or  between  the  bows,  or 
mounted  on  a  hinge  at  the  free  end  of  one  of  the  bows.  The 
first  two  varieties  of  catch  will  be  found  most  convenient  to 
those  sm-geons  who  are  accustomed  to  use  pressure-forceps  in 
abdominal  operations. 

If  there  be  any  difficulty  in  drawing  down  the  polypus,  a 
tenaculum-forceps  may  be  fixed  to  the  fundus  of  the  growth, 
and  the  polypus-forceps  can  then  be  applied  close  to  or  on  the 
pedicle,  but  as  a  rule  this  can  be  done  by  the  latter  instrmnent 
alone.  It  is  always  advisable  to  catch  the  pedicle  if  possible, 
for  when  the   polypus   is   grasped   by  its  fundus,  it  may  be 


REMOVAL    OY   A   MUCOUS   POLYPUS.  315 

simply  crushed,  so  tliat  tlie  forceps  comes  away  bringing  a 
small  piece  of  tissue  between  its  teetb,  and  a  lacerated  mass  is 
left  behind.  When  the  forceps  has  been  made  to  grasp  the 
pedicle  satisfactorily,  the  bows  of  that  instrument  are  slowly 
rotated  in  one  direction,  till  the  polypus  is  twisted  away.  The 
stump  of  the  pedicle  does  not  retract  to  such  an  extreme  extent 
as  that  of  a  fibrous  polypus. 

This  operation  is  generally  very  easy  of  performance,  the 
only  difficulty  arises  from  crushing  the  tissue  of  the  fundus,  as 
just  described.  It  should  never  be  performed  whilst  the  patient 
is  under  treatment  for  any  acute  or  sub-acute  form  of  pelvic 
inflammation.  It  is  not  a  safe  operation  when  a  large  fibroid 
tumour  of  the  uterus  exists,  or  when  the  uterus  is  infested  with 
small  fibroids.  I  was  called  upon,  in  1877,  to  make  a  necropsy 
of  a  woman  aged  fifty  who  had  suffered  from  a  large  fibroid 
tumour.  A  mucous  polypus,  about  two  inches  in  length,  had 
been  twisted  off  ten  days  before  death.  Septic  symptoms 
followed,  ultimately  there  were  marked  rigors,  yet  the  patient 
had  been  apparently  in  good  health  before  the  operation.  I 
found  an  abscess  in  the  right  ovary,  another  in  the  right  broad 
ligament,  and  a  third  below  it,  where  its  peritoneal  folds 
diverged.  There  was  diffuse  suppuration  in  the  cellular  tissue 
of  the  right  ovarian  vessels,  extending  from  an  inch  below  the 
kidney  to  the  brim  of  the  pelvis.  The  fibroid  was  a  large  myoma, 
eleven  inches  in  vertical  diameter ;  it  weighed  7  lbs.  11  ozs., 
and  had  developed  in  the  posterior  wall  of  the  uterus,  whence 
it  could  be  completely  enucleated,  and  its  only  vascular  supply 
were  three  large  vessels  running  from  the  walls  of  the  cervix 
close  to  the  os  externum.  There  was  no  pus  around  these 
vessels.  The  pedicle  of  the  polypus  sprang  from  the  anterior 
wall  of  the  uterus  close  above  the  os  internum.  It  looked  Hke 
a  long  decolourized  clot,  and  was  sloughy  at  its  extremity.  The 
kidneys  showed  signs  of  recent  congestion  ;  the  heart  was  large 
and  fiabby.  There  was  much  turbid  serimi  in  the  pericardium 
and  peritoneum. 

This  case  illustrates  the  dangers  of  interfering  with  a  mucous 
polypus  when  the  uterus  is  otherwise  in  a  morbid  condition. 
The  cervix  was  two  and  a  half  inches  in  length,  and  the 
■external  os  was  narrow,  so  that  there  was  not  sufficient  means 


316  OPERATIONS    ON    FIBROID    TUMOURS   AND    POLYPI. 

for  the  free  escape  of  discharges.  The  vagina  had  been  kept 
clean  b}'  injections.  When  the  patient  is  in  good  health  and  the 
polypus  is  troublesome,  projecting  into  the  vagina  and  giving 
rise  to  discharge  or  haemorrhage,  it  is  right  that  the  sm-geon 
should  advise  and  perform  the  operation.  The  patient  should 
rest  for  at  least  twenty-four  hours,  and  a  weak  solution  of 
Condy's  fluid  shoidd  be  injected  night  and  morning  into  the 
vagina. 


317 


CHAPTER  XII. 

VAGINAL   EXTIRPATION   OF   THE   UTERUS— AMPUTATION  OF   THE 
CERVIX— TRACHELORRHAPHY. 

Operations  for  Uterine  Cancer:  General  Observa- 
tions.— There  can  be  no  doubt  that,  compared  with  the  breast 
or  either  of  the  extremities,  the  uterus  is  in  a  highly  unfavour- 
able position  for  radical  operations,  when  it  is  subject  to  cancer. 
This  disease  almost  invariably  commences  at  the  cervix.  Ampu- 
tation of  the  cervix  by  the  ecraseur,  or  better  still  by  the  galvano- 
cautery,  is  still  the  most  popular  and  widely  practised  operation  ; 
it  is  far  less  difficult  than  more  extreme  measures,  and  is  not 
unsurgical,  for,  as  Koeberle  and  John  Williams  have  shown,  the 
disease  generally  begins  near  the  os  externum  and  spreads  over 
the  surface  of  the  cervix,  attacking  the  vagina  and  adjoinino- 
organs  before  it  mounts  upwards  beyond  the  level  of  the  os. 
Dr.  Williams  has  noted  the  important  fact  that  when  recurrence 
takes  place  after  supra- vaginal  amputation  of  the  cervix,  its  seat 
is  in  the  adjacent  connective  tissue  and  not  in  the  uterine  stump. 

Many  experienced  operators,  however,  often  prefer  more 
complete  operations  than  amputation  of  the  vaginal  portion  of 
the  cervix.  They  practise  supra-vaginal  amjDutation  of  the 
cervix — a  most  difficult  operation,  which  will  presently  be 
described — or  else  remove  the  uterus  completely.  Provided  that 
the  latter  be  done  through  the  vagina  and  not  by  abdominal 
section,  the  risk  is  not  very  high.  Brennecke  states  (see  Year 
Book  of  Treatmoit  for  1886)  that  "while  the  mortality,  as  o-iven 
by  Hoffmeier  for  supra- vaginal  amputation,  compared  with  total 
extirpation,  is  lower  (12  per  cent,  against  26) ;  return  of  disease 
occurred  in  28  per  cent,  of  the  total  extirpation  for  41-5  per 
cent,  of  the  partial."     Statistics  of   special   operators   in  this 


318  VAGINAL    EXTIRPATION    OF    THE    UTERUS. 

coimtrv,  and  particularly  in  Grermany,  have  displayed  almost 
brilliant  results,  but  the  mortality  in  nearly  three  hundred  cases 
oolleuted  by  Dr.  William  Duncan  exceeded  28  per  cent.  As  in 
the  case  of  oophorectomy,  the  general  surgeon  must  not  rely 
on  the  results  of  an  experience  which  he  may  not  possess. 

Cases  suitable  for  Total  Extirpation. — Koeberle  goes 
so  far  as  to  say  that  this  operation  is  only  justifiable  when 
rendered  relatively  simple  and  safe  by  the  existence  of  complete 
prolapse  of  the  uterus.  Cancer  beginning  in  the  body  of  the 
uterus — a  very  rare  condition — and  sarcoma  of  the  fundus  may 
be  treated  by  supra-vaginal  hysterectomy,  as  in  fibroid  disease, 
should  there  be  fair  evidence  that  the  morbid  growth  does  not 
extend  to  the  cervix.  The  objections  to  this  operation  for  the 
ordinary  form  of  cancer  will  be  stated  after  the  description  of 
supra -vaginal  amputation  of  the  cervix.  When  cancerous  disease 
has  evidently  advanced  high  up  the  cervical  canal,  as  in  the 
rarer  form  of  cancer  of  the  cervix  which  extends  upwards  and 
not  downwards,  and  when,  at  the  same  time,  the  mobility  of  the 
uterus  remains  unimpaired,  and  no  deposit*  can  be  felt  near  the 
cervix,  total  extirpation  may  be  considered  as  faii-ly  justifiable. 
The  state  of  the  broad  ligaments  and  adjacent  connective  tissue 
should  be  ascertained  by  rectal  and  recto-abdominal  exploration 
(see  pages  69,  71). 

Total  Extirpation  of  the  Uterus  through  the  Va- 
gina, t — The  instruments  required  for  this  operation  will  be — 


Clover's  crutch. 

Higginson's  syringe. 

Sims'  speculum. 

Strong  and  slender  volsellse. 
(Figs.  23,  120). 

Scalpel. 

Six  sponge-holders  with 
small  sponges. 

Two  paii's  of  long-handled 
scissors  bent  on  the  flat. 


Two  large  pressure-forceps, 
straight-bladed  (Fig.  40). 

Broad  metal  retractor. 

Nos.  1,  3  and  4  silk  twist  for 
ligature. 

Pedicle-needle  (Fig.  44), 
armed  with  No.  3  silk  ligature. 

Two  glass  drainage-tubes 
(page  126). 

Needle-holder. 


*  Induration  caused  by  cellulitis  ("parametritis"),  complicating  cancer, 
cannot  well  be  distinguished  from  true  cancerous  infiltration  of  the  connective 
tissue  around  the  cervix. 

t  Total  extirpation  of  the  uterus  by  abdominal  section  ("  Freund's  Operation") 


SEPARATION    OF    CERVIX    FROM    VAGINA.  319 

The  patient  is  laid  on  lier  back,  and  then  the  anaesthetic  is  ad- 
ministered. When  under  its  influence,  she  is  placed  in  lithotomy 
position,  and  it  will  greatly  economize  assistance  if  the  lower 
extremities  be  kept  apart  by  means  of  a  Clover's  crutch  (page 
132).  The  nates  are  brought  close  to  the  edge  of  the  operating 
table,  and  a  pan  is  placed  on  the  floor  vertically  below  the  seat 
of  operation.  The  operator  sits  on  a  stool  or  low  chair  facing 
the  perineum ;  the  chief  assistant  stands  on  his  right,  and  the 
chief  nurse  on  his  left  hand. 

The  vagina  is  thoroughly  washed  out  with  carboHzed  water, 
by  means  of  a  Higginson's  syringe.  A  Sims'  speculum  is  then 
passed  along  the  posterior  vaginal  wall.  The  cancerous  ulcer 
should  have  been  previously  plugged  with  iodoform  wool,  or 
otherwise  rendered  as  clean  as  possible.  The  anterior  lip  is 
then  seized  by  means  of  a  volsella  (Fig.  23),  and  the  uterus  is 
drawn  down  till  the  os  externum  is  brought  as  near  as  possible 
to  the  vulvar  aperture.  The  volsella  is  then  given  in  charge  of 
the  assistant. 

Separation  of  the  Cervix  from  the  Vagina  and  other  Struc- 
tures.—  The  assistant  grasps  the  volsella  with  his  left 
hand*  and  depresses  its  handles  so  as  to  pull  the  cervix  back- 
wards and  downwards.  The  operator  then  cuts  through  the 
vaginal  mucous  membrane  along  its  anterior  reflection  on  to  the 
cervix  by  means  of  the  scissors,  so  that  a  semi-circular  wound 
is  made  in  the  anterior  fornix,  with  its  convexity  forwards. 
From  this  stage  onwards  the  assistant  must  keep  the  haemor- 
rhage constantly  in  check,  by  means  of  the  mounted  sponges. 

A  catheter  is  passed  into  the  bladder.  The  anterior  part  of 
the  uterus  is  then  cut  away,  with  scissors,  from  its  cellular 
connections  with  the  bladder.  The  blades  of  the  instrument 
must  be  kept  close  to  the  uterus.  The  peritoneum  should  not 
be  opened  at  this  stage,  for  in  attempting  to  cut  through  it 
the  operator,  as  I  have  witnessed,  may  push  it  upwards  out  of 
reach,  and  even  partially  detach  it  from  the  uterus.      If  the 

is  very  perilous,  and  appears  to  be  almost  discarded.     I  shall  presently  describe 
a  case  of  a  kindred  form  of  operation  where  the  cancerous  uterus  was  pregnant. 

*  The  operator  will  require  his  left  forefinger  to  explore  the  structures  through 
which  he  cuts.  It  is,  therefore,  not  advisable  for  him  tx)  hold  the  volsella  in  his 
left  hand. 


320  VAGINAL    EXTIRPATION    OF    THE    UTERUS. 

mucous  membrane  be  really  cut  through,  the  viscera  may  be 
wounded. 

The  speculum  is  now  removed  and  the  cervix  completely  sepa- 
rated from  the  vaginal  mucous  membrane.  To  do  this,  the  assis- 
tant should  seize  the  posterior  lip  of  the  os  with  the  volsella, 
and  draw  the  cervix  downwards  and  well  forwards,  so  as  to  bring 
its  posterior  aspect  into  view.  Then  the  operator  divides  the 
vaginal  mucous  membrane  along  its  posterior  reflection  on  to  the 
cervix  with  the  scissors  ;  in  this  manner  another  semi- circular 
wound  is  made,  its  ends  uniting  with  those  of  the  first,  which 
He  to  the  front  of  the  cervix.  As  before,  the  scissors  must  be 
kept  close  to  the  cervical  tissue. 

The  cervix  being  thus  detached,  Douglas's  pouch  is  now 
■opened  up.  Care  must  be  taken  not  to  cut  too  far  laterally, 
lest  the  broad  ligaments  be  wounded. 

At  this  stage  of  the  operation  the  uterus  will  remain  con- 
nected to  surrounding  parts  by  the  broad  ligaments  and  the 
utero-vesical  fold  of  peritoneum.  Some  operators  secure  and 
divide  the  ligaments  first.  It  is  best,  except  in  cases  where 
some  peculiarity  due  to  the  extent  and  direction  of  the  morbid 
growth  or  any  unforeseen  contingency  renders  it  advisable,  in 
the  opinion  of  the  surgeon,  to  proceed  in  an  opposite  manner, 
to  divide  the  remaining  peritoneal  connection  first.  Otherwise 
the  broad  ligament  will  be  less  accessible  and  too  tense  for  the 
safe  application  of  the  ligature. 

The  utero-vesical  fold  of  peritoneum  should,  therefore,  be 
divided.  In  order  to  do  so,  the  operator  slips  his  left  fore- 
finger (and  middle  finger  as  well,  if  there  be  room)  through  the 
hole  in  Douglas's  pouch,  over  the  fundus  and  front  of  the  body 
of  the  uterus,  till  the  point  of  the  finger  presses  on  the 
reflection  of  peritoneum  from  the  bladder  on  to  the  uterus. 
The  peritoneum  is .  then  divided  by  a  scalpel  or  scissors,  the 
operator  holding  the  instrument  in  his  right  hand,  and  cutting 
close  against  the  uterus  :  the  finger  behind  the  peritoneum 
serves  as  a  guide.  The  catheter  should  remain  in  the  bladder 
at  this  stage  of  the  operation.  The  above  manceuvres  are  much 
simplified  should  the  uterus  happen  to  be  retroflexed. 

The  uterus  is  now  entirely  free,  excepting  at  its  lateral 
connections  with  the  broad  ligaments,  which  have  been  rendered 


SECURING    THE    BROAD    LIGAMENTS.  321 

as  accessible  as  possible  by  the  previous  dissection.  The  operator 
should  calmly  and  deliberately  explore  them,  so  as  to  recognize 
thoroughly  what  he  is  about.  He  must  avoid  pushing  malig- 
nant tissue  into  the  peritoneal  cavity. 

Securing  the  Broad  Ligaments. — In  order  to  ^Qt  at  the 
broad  ligaments  for  the  purpose  of  securing  them  as  safely 
as  possible,  the  fundus  is  pulled  through  the  posterior  part  of 
the  wound,  with  the  aid  of  a  strong  volsella  (Fig.  120) — that 
which  has  held  the  cervix  should  not  be  used — or  a  large 
pressure-forceps  (Fig.  40).  This  forcible  retroflexion  of  the 
uterus  is  especially  necessary  when  that  organ  is  bulky.  It  is, 
however,  never  very  easy  to  effect.  The  right  hand  should  be 
pressed  on  the  hypogastrium,  whilst  the  left  forefinger  is  passed 
through  the  posterior  part  of  the  wound,  and  hooked  over  the 
fundus.  When  the  body  of  the  uterus  is  pulled  clown  into  the 
wound,  the  operator  must  take  hold  of  it  with  the  volsella  or 
forceps  held  in  his  right  hand. 

The  broad  ligaments  must  now  be  secured.  When  that  is 
effected,  all  sources  of  haemorrhage  will  be  controlled,  since  the 
uterine  and  ovarian  arteries  will  then  be  included  in  the  forceps 
or  ligature  applied  to  the  ligaments  (b  b,  Fig.  12,  page  42). 
This  part  of  the  operation  is  the  most  dangerous.  The  removal 
of  the  ovaries  and  tubes  entire  is  desirable,  and  it  is  especially 
important  that  the  tubes — integral  parts  of  the  cancer-infected 
uterus — should  come  away.  When  the  ovary  is  left  behind,  the 
patient  is  liable  to  suffer  from  distressing  pain  during  the 
menstrual  period.  Unfortunately,  whilst  the  transfixion  and 
ligature  of  the  broad  hgament  on  the  uterine  side  of  the  ovary 
are  comparatively  easy  and  safe,  the  application  of  the  ligatiu-e 
external  to  the  ovary  and  tube  is  very  difficult  and  hazardous. 
In  tying  the  ligature  in  ovariotomy,  the  pedicle,  ah'eady  kept 
moderately  tense  and  well  in  sight  during  transfixion,  can  be 
relaxed  as  the  loop  is  drawn  tight.  Thus,  the  operator  can  see 
Avhere  he  has  applied  the  ligature,  and.  by  being  able  to 
relax  the  pedicle,  can  make  sure  that  it  is  drawn  tight 
enough.  In  vaginal  extirpation  of  the  uterus,  the  structures 
to  be  transfixed  can  never  be  brought  so  well  into  view,  and 
it  is  very  difficult  to  be  able  to  relax  the  ligament  sufficiently  as 
the  loop  is  being  tied.     In  order  to  understand  this,  the  sm-geon 

Y 


322  VAGINAL    EXTIRPATION    OF    THE    UTERUS. 

need  only  remember  that  the  ligament  is  drawn  down  close  to 
the  vulva,  and  that,  if  the  appendages  are  to  be  amputated 
entire,  the  ovarian  vessels  in  the  infundibulo-pelvic  ligament, 
naturally  high  in  the  pelvis,  have  to  be  tied.  They  must,  it  is 
clear,  be  made  very  tense,  in  order  to  allow  of  the  necessary 
manipulation. 

In  one  case  where  I  was  present,  the  pedicle  was  transfixed 
on  each  side  external  to  the  tube  and  ov^ary  with  comparative 
ease.  The  vagina  and  pelvis  were  capacious,  and  the  tubes  and 
ovaries  could  be  brought  fairl}^  into  sight.  Just  as  the  opera- 
tion was  being  concluded  violent  haemorrhage  occurred,  and  the 
abdominal  aorta  needed  compression.  The  ligature  on  the 
stump  of  the  left  pedicle  had  given  way.  Sir  Spencer  Wells' 
advice  was  followed,  and  cyst-forceps  were  apphed  to  both 
pedicles.     The  patient  died,  but  not  from  haemorrhage. 

I  have  kno"^Ti  the  uterus,  not  in  itself  very  bulky,  to  block  up 
the  vagina  to  such  an  extent,  that  onlj^  the  left  broad  ligament 
could  be  reached.  It  was  therefore  secured,  and  the  uterus 
was  then  cut  verticall}'  into  halves,  from  the  fundus  to  the 
cervix,  by  means  of  the  scissors.  The  right  half  hardly  bled  at 
all,  as  its  vessels  in  the  unsecured  right  broad  ligament  were 
stretched  and  t^dsted.  The  left  half  of  the  uterus  was  cut 
fiway,  then  the  right  broad  ligament  was  readily  transfixed 
and  ligatm-ed.  i 

I  believe  that  the  above  manoeuvre,  originally  practised  by 
Dr.  A.  R.  Simpson,  is  frequently  advisable.  In  any  case,  when 
the  broad  ligament  is  secm-ed,  a  straight-bladed  large  pressure- 
forceps  (Fig.  40)  must  be  made  to  hold  it  close  to  the  uterus. 
A  strongly-curved  pedicle-needle  (Fig.  44),  armed  with  Xo.  3 
or  4  silk,  is  made  to  transfix  the  broad  Hgament  from  behind, 
external  to  the  forceps.  The  ligatm-e  is  then  secm^ed,  as  in 
ovariotomy  (Figs.  103,  104).  As  the  ends  of  the  thread  are 
being  pulled  tight,  the  assistant  must  remove  the  large  pressiu-e- 
forceps.  The  ends  of  the  other  thread  are  then  tied  round  the 
opposite  side  of  the  broad  ligament. 

The  broad  ligament  is  now  cut  tlirough  between  the  ligatm-e 
and  the  uterus ;  the  ends  of  the  ligatm^e  should  be  left  uncut 
till  the  vaginal  wound  has  been  attended  to,  later  on.  The 
uterus  is  then  drawn  to  the  ligatm-ed  side,  and  the  opposite 


SECUKING    THE    BROAD    LIGAMENTS THE   VAGINAL    WOUND.       3'2'i 

broad  ligament  is  secured  in  the  same  manner.  Many  operators 
tie  a  single  ligature  round  each  broad  ligament,  sinking  it  into 
the  groove  already  formed  by  the  transfixing  ligatm-es.  Dr. 
W.  Duncan  employs  a  broad  flat  retractor  to  facilitate  this 
stage  of  the  operation. 

I  have  been  speaking  of  the  ligature  and  division  of  the 
broad  ligament  on  the  uterine  side  of  the  ovary.  When  the 
ovary  and  the  fimbriated  extremity  of  the  Fallopian  tube  are 
removed,  the  process  will  be  far  more  difficult.  In  some 
cases  the  proximal  side  of  the  ligament  will  be  so  tense  that 
no  ligatures  can  be  trusted ;  then  it  must  be  seized  with  a  large 
pressure-forceps,  which  is  left  on  for  a  day  or  two.  The  forceps 
is,  however,  no  sheet-anchor  in  this  operation.  It  compresses 
much  tissue  besides  the  vessels  which  it  is  designed  to  secure, 
and  may  set  up  sloughing ;  it  may  also  tear  away  by  its  own 
weight  if  improperly  supported.  It  takes  up  much  room  in 
the  vagina,  and  I  have  known  it  to  cause  very  severe  pain.  It 
does  not  always  succeed  in  stopping  haemorrhage.  In  one 
operation,  where  I  was  assistant,  I  noticed  that  it  crushed  the 
structures  of  the  broad  ligament  and  made  them  bleed ;  but, 
fortunately,  in  this  case  the  forceps  had  been  applied  on  the 
distal  side  of  the  ligature. 

Reitioval  of  the  Uterus. — Both  broad  ligaments  having  been 
divided,  the  uterus  now  comes  away.  The  cut  surfaces  of  the 
pedicles  should  be  inspected,  and  any  bleeding  points  must  be 
secured  by  ligatm^e,  or,  if  more  convenient,  by  pressure-forceps, 
which  must  be  left  on  for  six  or  eight  hours. 

TJie  Treatment  of  tJte  Vaginal  Wound  :  The  Question  of  Brain- 
age. — The  vaginal  wound,  after  the  removal  of  the  uterus, 
appears  smaller  than  the  inexperienced  operator  miglit  perhaps 
expect.  Through  it  omentmii,  or  the  remains  of  the  append- 
ages, are  apt  to  prolapse.  Some  operators  simply  leave  the 
flaps  of  the  vaginal  wound  free  after  pushing  up  any  prolapsed 
structure,  using  no  sutm^es,  and  trusting  to  the  packing  of  the 
vagina  to  prevent  further  prolapse.  When  the  operator  prefers 
to  close  the  wound,  a  cmwed  needle,  armed  with  No.  3  silk,  is 
passed,  by  the  aid  of  a  needle-holder,  through  the  anterior 
fornix,  close  to  the  edge  of  the  wound,  and  near  its  outer 
extremity.     It  is  then  made   to  transfix   one  pedicle,  and   to 


324  VAGINAL    EXTIRPATION    OF    THE    UTERUS. 

emerge  close  to  the  opposite  edge  of  the  wound  through  the 
tissues  of  the  posterior  fornix.  The  sutiu'e  is  then  tied,  and  the 
other  pedicle  is  treated  in  the  same  manner.  The  inclusion 
of  the  pedicles  is  never  easy,  and  may  be  impossible. 

The  propriety  of  drainage  is  much  disputed.  Some  siu'geons 
sew  up  the  wound*  after  pushing  the  stumps  of  the  appendages, 
with  the  ligatm^es  cut  short,  into  the  abdominal  cavity  ;  drainage 
is  probably  advisable  in  most  cases.  The  simplest  form  is  a 
long  Keith's  drainage-tube  (Fig.  55)  ;  this  is  passed  about  half 
an  inch  beyond  the  vaginal  wound.  The  vagina  is  then  packed 
with  iodoform-wool,  put  in  piece  by  piece,  with  the  aid  of  a 
speculum-forceps  (Fig.  15).  It  is  advisable  to  blow  iodoform 
l>owder  over  each  pledget,  by  the  aid  of  an  insufflator  (Fig.  63). 
Dr.  "VV.  A.  Duncan  has  de-^dsecl  a  T-shaped  di-ainage-tube,  so 
arranged  as  to  allow  of  washing-out  the  parts  very  effectually 
(see  "  On  Extii'pation  of  the  Entire  Uterus,"  Tranmdions  of 
the  OhstctricdJ  Societf/,  vol.  xxvii.,  1885,  page  11). 

The  question  is  not  settled.  Five  years  ago,  when  making  a 
necropsy  on  a  patient  who  died  on  the  second  day  after  this 
operation,  where  no  tube  had  been  inserted,  I  found  a  pool  of 
l)rick-dust  colonized  fluid  in  the  hollow  in  front  of  the  sacrum. 
It  is  difficult  to  understand  how  that  part,  perfectly  dependent 
as  the  patient  lay  on  her  back,  could  have  been  readily  drained. 
The  peritoneal  relations  are  greatly  altered,  and  it  is  not  easy 
for  the  operator  to  know  where  to  place  the  end  of  the  tube  to 
ensm-e  escape  of  sermn.  "When  he  employs  the  tube,  the  point 
should  simply  he  a  little  within  the  vaginal  wound. 

DresHtng  of  the  Case  and  Management  after  Operation. — A  thick 
pad  of  iodoform-wool  is  laid  over  the  vulva  after  the  vagina 
has  been  dressed ;  and  a  sponge  is  placed  over  the  mouth  of 
the  drainage-tube,  if  that  appliance  has  been  employed.  The 
iodoform-wool  plugs  must  be  frequently  inspected  and  changed. 
"When  the  drainage-tube  is  used  the  pelvic  cavity  must  be 
washed  out,  shoidd  the  temperatm'e  rise  high  or  the  discharge 
from  the  tube  become  foetid.  The  sutui-es  in  the  vaginal  wound 
must  be  removed  at  the  end  of  a  fortnight,  a  Sims'  speculum 
being  passed  along  the  posterior  wall  of  the  vagina  after  the 

*  Dr.  Staudc,  of  Hamburgh,  uses  a  continuous  catgut  suture. 


AMPUTATION    OF    THE    CERVIX    TTERl.  325 

patient  has  been  placed  on  her  back,  so  as  to  bring  the  wound 
well  into  view. 


Amputation  of  the  Cervix. — This  operation  is  performed 
either  for  malignant  disease,  or  for  the  cure  of  the  troublesome 
results  which  may  follow  hypertrophic  elongation  of  the  cervix. 
The  question  of  operation  in  malignant  disease  has  been  dis- 
cussed in  relation  to  the  total  extirpation  of  the  uterus.  Ampu- 
tation as  performed  for  malignant  disease  will  first  be  described. 
In  cases  of  hypertrophic  elongation,  the  same  kind  of  amputa- 
tion is  often  adopted,  but  some  authorities  add  certain  plastic 
proceedings. 

Amputation  of  the  cervix  may  be  performed  after  several 
distinct  methods.  I  shall  describe  amputation  by  the  galvano- 
cautery  and  by  the  ecraseur ;  supra- vaginal  amputation,  or 
complete  removal  of  the  cervix  by  the  knife ;  amputation  by  the 
knife  with  application  of  caustics  ;  and  amputation  of  the  vaginal 
portion  of  the  cervix  by  the  knife  and  scissors.  The  first  three  are 
more  frequently  performed  in  this  country  than  the  remainder. 

Amputation  of  the  Cervix  Uteri  by  the  Galvano- 
Cautery.* — The  patient  having  been  brought  under  the  influ- 
ence of  an  anaesthetic  is  placed  in  the  lithotomy  position.  The 
knees  are  held  apart  by  assistants  or  a  Clover's  crutch  (page 
132).  A  Sims'  speculum  is  introduced  into  the  vagina,  and  the 
cancerous  cer\dx  is  secured  by  the  volsella.  This  may  be 
drawn  down  very  gently,  as  the  cancerous  tissues  are  readily 
torn.  The  volsella  should  be  made  to  seize,  as  far  as 
possible,  healthy  tissue  above  the  diseased  portion  of  the  cervix, 
care  being  taken  to  avoid  Douglas's  pouch  behind  and  the 
bladder  in  front. 

The  loop  of  platinum  wire  (Fig.  70,  page  152)  is  passed 
over  the  handles  of  the  volsella,  and  adjusted  above  its  prongs 
while  the  wire  is  cold.  The  wire  is  then  cbawn  tight  enough 
to  touch  evenly  all  round  the  part  of  the  cervix  to  be  removed. 
Care  is  again  taken  to  avoid,  if  possible,  Douglas's  pouch,  and 
a  firm  stout  catheter  is  passed  into  the  bladder  and  pushed  up 
so  as  to  raise  it  out  of  danger.     If  the  shape  of  the  cervix  be 

*  This  description  of  the  operation  is  ^vritten  by  Dr.  Steavenson.  See  Intro- 
duction to  Chapter  V. 


326  AMPUTATIOX    OF    THE    CERVIX. 

such  that  the  wire  easily  shps  clowu  on  to  the  TolseUa,  it  can  be 
kept  iu  its  jilace  by  an  ivory  pin  passed  through  the  tissues, 
just  below  the  part  thi'ough  which  it  is  desired  that  the  wire 
should  burn  its  way. 

When  the  operator  is  perfectly  satisfied  that  the  wire  is  in 
the  right  position  the  circuit  is  closed,  and  he  orders  his 
assistant  to  increase  gradually  the  strength  of  the  current  until 
a  slight  hissing  sound  proclaims  that  the  wu'e  is  hot,  and  has 
commenced  burning  its  way  through  the  mucous  membrane. 
This  must  be  done  slowly,  and  the  wire  should,  if  possible,  be 
kept  at  a  dull  red  heat.  It  is  seldom  that  the  operator  or  his 
assistant  can  see  the  colour  of  the  wii-e ;  they  will  therefore  have 
to  be  guided  to  a  great  extent  by  the  slight  amount  of  smoke 
and  hissing  noise  produced.  The  operator  can  also  feel,  by 
keeping  slight  traction  on  the  wire,  whether  it  is  passing  too 
easily  and  Cjuickly  thi'ough  the  tissues.  The  traction  main- 
tained should  be  just  sufficient  to  keep  the  wire  tight  against 
the  unsevered  part  of  the  cervix,  and  not  enough  to  make  the 
wire  itseK  cut  through.  The  ^vii'e  ought  to  progress  simply  b}' 
its  cauterizing  action.  If  the  traction  be  so  great  as  to  make 
the  wii'e  cut  its  way  thi"Ough  as  with  an  ordinary  ecraseur,  or  if 
the  wire  be  raised  to  a  white  heat — in  which  case  it  cuts  as  freely 
and  quickly  as  a  knife — heemon-hage  will  follow,  and  one  of 
the  great  advantages  of  the  galvanic  ecraseur  will  be  lost.  If 
the  wii-e  be  used,  as  it  ought  to  be,  at  a  dull  red  heat,  the  ends 
of  the  severed  vessels  are  closed  by  its  cauterizing  action  as  it 
proceeds  through  the  tissues,  and  the  ends  of  the  nerve  are  also 
destroyed  as  in  a  burn  of  the  third  degree,  so  that  the  after- 
pain  is  less  than  when  the  knife  or  ordinary  ecraseur  is  employed. 
Should  the  wire  slip  duiing  the  progress  of  the  operation  the 
cu'cuit  must  be  broken,  and  in  a  few  seconds  the  wire  will  have 
cooled  down  sulficiently  for  the  operator  to  readjust  it  with  his 
fingers.  If  the  wii'e  proceed  in  the  desired  direction,  no  inter- 
ruptions are  necessary  for  the  pm-pose  of  injecting  ice-cold 
water  to  cool  the  parts,  as  directed  by  some  writers.  The  wire 
is  speedily  cooled,  if  necessary,  by  breaking  the  cii'cuit,  and  the 
vagina  and  vulva  can  be  well  protected  by  ivory  retractors. 
Care  should  be  taken  that  the  conducting  metal  rods  of  the 
ecraseui'  do  not  come  in  contact  with  the  metal  speculum  or 


AMPUTATIOX    BY   THE    GALVAIN'O-CAUTERY.  327 

blades  of  the  volsella,  as  the  current  might  thereby  be  short 
circuited.  It  is  often  an  advantage  from  time  to  time  to  arrest 
the  cm-rent,  so  that  the  operator  may  ascertain  with  his  finger 
whether  the  wire  is  burning  its  way  through  in  the  direction  he 
wishes. 

When  the  part  to  be  removed  is  quite  severed  the  loop  will 
have  disappeared,  and  the  short  remaining  portion  of  the  wire  is 
found  quite  tightly  approximated  to  the  small  piece  of  porcelain 
which  keeps  apart  the  ends  of  the  conducting  rods. 

The  serious  consequences  which  may  follow  the  opening  of 
Douglas's  pouch  are  not  so  great  when  the  galvanic  ecraseui*  is 
used  as  with  other  modes  of  performing  the  operation.  In 
the  account  of  the  operation  given  by  Dr.  Karl  Pawlik  in  the 
Wiener  Klinik,  Jahrgang  viii.,  Heft  xii.,  1882,  many  operations 
are  mentioned  in  which  Douglas's  pouch  was  opened  without  any 
serious  consequences.  It  was  found  that,  in  most  cases,  the  hot 
wire  glued  together  the  severed  sm-faces  of  the  peritoneum,  and 
no  ill  result  followed.  This  advantage  of  the  galvanic  over  all 
other  methods  of  removal  of  the  cervix  uteri  must  be  borne  in 
mind  when  deciding  what  means  to  adopt.  It  is  not  difficult  to 
determine,  by  examination  of  the  eschar  on  the  stump,  whether 
any  cancerous  material  is  left,  as  such  material  will  appear  as 
a  raised  whitish -coloured  tissue  on  what  ought  to  be  an  even 
browner-coloured  burnt  surface  marked  by  crescentic  lines, 
showing  the  progress  of  the  wire.  Should  any  diseased  tissue 
be  left  it  may  be  removed  by  readjusting  the  galvanic  ecrasem* 
and  again  proceeding  as  abeady  described;  or  a  Yolkmann's 
spoon  may  be  used  to  scrape  out  all  the  cancerous  substance, 
and  the  cavity  thereby  made  cauterized  by  a  galvano-cautery 
p»orcelain  point  (page  151).  Atresia  of  the  os  is  said  to  follow 
the  removal  of  the  cervix  uteri  by  galvano-cautery,  but  this 
drawback  to  the  operation  does  not  occur  nearly  so  frequently 
as  is  supposed,  and  when  it  does  take  place  it  is  easily  remedied, 
either  by  dilating  the  os  by  graduated  bougies  or  by  the  use  of 
electrolysis  in  the  same  way  as  it  is  emploj^ed  for  strictm-es  in 
other  parts  ;  the  passage  will  then  be  speedily  restored  to  its 
normal  calibre. 

The  eschar  left  after  removal  of  the  cervix  uteri  by  galvano- 
cautery  separates  in  from  eight  to  fourteen  days.     Antiseptic 


328  AMPUTATION    OF    THE    CERVIX. 

solutions  may  be  injected  daily  into  the  vagina  before  and  after 
the  separation  of  the  eschar,  except  when  the  peritoneum  has 
been  opened,  when  it  is  advisable  not  to  use  any  injection  until 
the  eschar  has  come  away,  by  which  time  the  wound  in  the 
peritoneum  T^dll  have  become  healed.  Should  any  hfemorrhage 
take  j)lace,  either  at  the  time  of  the  operation  or  subsequently, 
it  can  be  best  arrested  by  the  application  of  the  galvano-cautery 
j)orcelain  point,  or  by  the  Paquelin's  cautery.  The  objections 
to  the  latter  method  are  that  its  action  cannot  be  so  easily 
limited  as  with  the  galvano-cautery  point,  and  more  tissue  is 
destroyed  than  is  necessary.  It  is  liable  to  injure  the  vulva  or 
vagina  at  its  introduction  or  removal,  and  the  suif  ering  is  greater 
if  used  without  an  anaesthetic. 

Whatever  may  be  the  relative  results  of  this  operation,  of 
total  extirpation  of  the  uterus,  and  of  supra-vaginal  amputation 
of  the  cervix  in  the  practice  of  experts,  amputation  by  the 
galvano-cautery  is  probably  the  favourite  and  certainly  the 
more  advisable  proceeding  for  general  sm'geons,  and  for  those 
who  have  not  operated  extensively  on  the  female  organs.  It  is 
very  probable  that  it  may  entirely  replace  the  other  two  opera- 
tions, which,  though  described  in  this  manual  because  largel}^ 
practised,  are  considered  by  many  authorities  as  somewhat 
desperate  undertakings  (see  page  317). 

Amputation  by  the  ^craseur. — There  are  often  certain 
difficulties  in  the  way  of  the  galvano-cautery ;  the  battery 
is  not  very  portable,  and  it  may  happen  that  when  the  surgeon 
is  ready  to  operate,  the  cautery  cannot  be  made  to  act,  owing  to 
some  mismanagement  on  the  part  of  assistants.  Hence,  the 
ecraseur  is  preferred  by  some  operators.  It  is  by  no  means  so 
safe  as  the  cautery.  The  wire  is  apt  to  drag  down  the  posterior 
fornix,  and  to  tear  through  Douglas's  pouch,  and  then  the  results 
are  certainly  more  serious  than  when  the  same  parts  are  acci- 
dentally damaged  by  the  cautery  wire. 

The  ecraseur  is,  on  the  other  hand,  very  portable,  and  when 
the  siu^geon  happens  to  be  accustomed  to  operate  on  the  cervix 
and  on  jiarts  in  its  neighboiu-hood,  or  has  used  that  instrument 
frequently  on  other  parts,  he  may  feel  justified  in  preferring  it 
to  the  galvano-cautery.  The  straight  ecrasem-,  as  used  in  ampu- 
tating the  tongue,  is  dangerous,  as  the  cervix  must  be  drawn 


AMPUTATION    BY    THE    ECRASEUR. 


329 


very  low  down  before  the  cliaiii  can  be  applied. 

the  risk  of  tearing  diseased 

parts  of  the  cervix,  and  of 

disturbing  any  products  of 

inflammation    which     may 

happen  to  lie  near  the  cervix 

above  the  vagina.    Hence,  it 

is  best  to  employ  a  ciu-ved 

ecraseur  (Fig.  124). 

The  patient  should  be 
placed  in  the  lithotomy  posi- 
tion, with  the  knees  secured 
by  a  crutch  (page  132). 
Experienced  operators  with 
experienced  assistants  often 
prefer  the  semi-prone  pos- 
ti.u'e.  The  parts  are  cleaned 
by  free  application  of  tepid 
water,  thrown  up  by  means 
of  a  Higginson's  syringe, 
and  subsequent  sponging, 
small  sponges  mounted  on 
holders  being  necessary. 
The  point  of  the  instrument 
is  then  passed  into  the 
posterior  fornix,  and  the 
■chain  is  slipped  round  the 
•cervix  above  the  level  of 
the  cancerous  growth  and 
made  fast  in  the  usual 
manner.  The  reflection  of 
the  vaginal  mucous  mem- 
brane on  to  the  cervix  must 
be  avoided.  The  chain  is 
then  made  firmer  at  in- 
tervals of  half  a  minute, 
until  the  parts  are  cut 
through.  The  handle  must 
only  be  worked  once  at  each 


This  entails 


Fig.  124. — CrEVED  Ecraseur. 


330  AMPUTAT10^"    OF    THE    CERVIX. 

interval.  The  after-treatment  will  be  the  same  as  when  the 
galvano-c-autery  is  emploj^ed. 

Supra- Vaginal  Excision  of  the  Cervix. — When  the 
knife  is  employed  it  is  advisable  to  remove  the  entire  cervix. 
This  can  be  done  b}'  an  operation  which  in  many  respects 
resembles  total  extirpation  of  the  uterus.  The  operation  is 
of  necessity  diificult,  and  the  inexperienced  must  not  be  misled 
by  the  statistics  of  skilled  specialists,  which,  in  these  cases,  are 
not  so  verj'  brilhant.  Sckroder's  mortality  was  but  12'37  per 
cent.,  but  others  cannot  claim  so  low  a  percentage.  Demon- 
strations, diagrams,  and  experiments  on  dead  subjects  make 
operations  of  this  kind  look  ahnost  easy,  but  the  rules  for 
avoiding  ureters,  uterine  arteries,  and  other  important  structures 
are  less  easy  to  follow  on  a  live  patient,  especially  when  ana- 
tomical relations  are   greatly  disturbed  by  morbid  conditions. 

Schroder's  operation  for  the  supra- vaginal  amputation  of  the 
cer^dx  is  thus  performed  :  The  patient  being  placed  in  lithotomy 
position,  and  the  knees  fixed  by  the  crutch  (page  132),  the 
cervix  is  seized  by  two  volselliTe,  the  fundus  being  depressed  by 
the  hand  of  an  assistant,  applied  to  the  hypogastriimi.  The 
cervix  is  then  drawn  down  to  the  vulva,  and  the  anterior  re- 
flection of  vaginal  mucous  membrane  is  divided  by  a  scalpel  or 
blunt-pointed  scissors.  The  bladder  is  separated  from  its  con- 
nections with  the  cervix  (see  Fig.  10)  by  the  finger,  or  by  the 
handle  of  a  scalpel  pressed  against  the  cervix,  which  is  held 
fii'mly  by  the  two  volselloe  in  the  operator's  left  hand.  The 
reflection  of  the  peritoneum  on  to  the  bladder  must  not  be 
divided ;  it  is  easih-  pushed  upwards.  Should  the  tissues  be 
healthy,  and  not  infiltrated  with  inflammatory  products,  this 
dissection  is  not  verv  difficult,  and  the  bladder  and  m-eters  will 
readily  be  pushed  upwards  out  of  harm's  way.  Unfortunately, 
infiltration  is  not  rare  in  the  neighbourhood  of  cancerous 
disease.  In  any  case,  however,  there  is  little  danger  of 
damaging  the  ureters,  if  the  surgeon  dissect  close  to  the 
tissues  of  the  cervix.  Dming  this  dissection  the  assistant 
must  clean  the  parts  fi-eely  with  small  sponges  mounted  on 
holders. 

The  cervix  is  next  pulled  towards  the  pubes  by  means  of  the 
volselloe.     The  surgeon  cuts  through  the  posterior  reflection  of 


SUPRA-VAGINAL    EXCISION.  331 

vaginal  mucous  membi-ane,  bringing  the  knife  or  scissors  round 
to  botli  extremities  of  the  anterior  incision,  so  as  to  fi'ee  the 
cervix  from  the  vagina  entireh'.  Douglas's  pouch  is  some- 
times laid  open. 

The  surgeon  must  now  separate  the  supra- vaginal  part  of  the 
cervix  from  its  lateral  connections.  This  part  of  the  operation 
is  difficult  and  dangerous,  and  since  the  body  of  the  uterus  is 
not  to  be  removed,  the  broad  ligaments  cannot  be  secured  as 
in  the  operation  for  total  extirpation  (see  page  321).  Small 
pressure-forceps  should  be  at  hand,  and  may  be  applied  to  the 
dense  connective  tissue  -SA^hich  surrounds  the  cervix.  The 
.  scissors  are  then  applied  to  the  uterine  side  of  the  forceps, 
till  the  connective  tissue  is  entirely  cut  away  from  the  cervix. 
Then  silk  ligatures  must  be  passed  round  the  tissue  grasped  by 
each  of  the  forceps.  Experienced  operators  secm-e  and  tie  the 
vessels  as  they  are  divided,  but  the  tissues  retract,  so  that  this 
process  is  very  difficult.  The  uterine  artery  itself  does  not 
touch  the  uterus  till  it  rises  above  the  level  of  the  uppermost 
part  of  the  cervix  (see  Fig.  12,  page  42),  but  the  secondary 
branches  of  the  artery  of  the  cervix  (see  page  41)  are  abundant, 
and  enter  the  surface  of  the  supra-vaginal  part  of  the  cervix 
almost  at  right  angles,  so  that  they  must  be  divided.  The 
ureters  have  abeady  been  pushed  upwards  with  the  bladder. 

The  process  of  amputation  must  now  be  commenced.  Thi& 
must  be  performed  after  Schroder's  ingenious  and  simple  plan 
for  avoiding  inconvenient  retraction  of  the  divided  parts.*  A 
scalpel  is  made  to  cut  through  the  anterior  part  of  the  cervix 
only,  the  incision  being  carried  obliquely  upwards  towards  the 
cervical  canal,  and  at  a  sufficiently  high  level  in  the  supra- 
vaginal portion,  well  above  the  malignant  growth.  The 
cervical  canal  must  be  exposed  ;  then  the  cut  surface  of  the 
cervix  is  united  by  silk  sutures  to  the  anterior  vaginal  wall. 
This  is  done  by  means  of  a  strongly  cui'ved  needle,  grasped 
by  a  holder. 

When  the  stump  of  the  anterior  part  of  the  cervix  has  been 
thus  secured,  the  posterior  portion  is  amputated  in  a  similar 
manner,  the  knife  being  carried  from  the  cervical  canal  some- 

*  It  has  been  adopted  by  Dr.  John  Williams  and  other  British  authorities, 
who  have  had  considerable  experience  in  this  operation. 


332  AMPUTATIOX    OF    THE    CEKVIX. 

■u'liat  downwards  to  the  surface  of  the  cervix.  In  this  way,  a 
wedge-shaped  incision  will  have  been  made,  with  the  apex  on 
the  stump  pointing  upwards.  The  stump  of  the  posterior  part 
of  the  cervix  is  sewn  to  the  posterior  vaginal  wall. 

The  lateral  parts  of  the  vaginal  walls  must,  lastly,  be  united 
by  silk  sutures  passed  deeply  through  the  superjacent  structures. 
This  practice  controls  haemorrhage,  as  experience  has  shown. 

The  vagina  must  be  carefully  syringed  out  night  and  morn- 
ing for  a  week  or  ten  days  after  operation  ;  at  the  end  of  that 
term  the  sutures  are  removed.  For  this  purpose,  the  patient 
should  be  placed  in  the  semi-prone  position. 

Amputation  and  Caustics. — In  any  operation  where 
the  cervix  is  amputated,  the  siu^face  of  the  stump  should  be 
examined,  especiall}^  where  the  cervical  canal  is  exposed,  and 
any  suspicious  tissue  should  be  destroyed  by  the  cautery  or 
solid  chloride  of  zinc. 

Sims  and  Schroder  have  advocated  the  systematic  combina- 
tion of  excision  with  caustics.  The  cancerous  mass  is  first 
broken  down  till  its  base  is  reached.  The  surgeon  should 
never  do  this  with  his  forefinger.  I  know  of  a  case  where 
an  operator,  a  most  accomplished  obstetrician,  was  laid  up  for 
several  weeks  with  severe  inflammation  of  the  hand  in  conse- 
quence of  using  his  finger  in  this  manner.  A  pair  of  scissors, 
curved  on  the  flat,  will  remove  the  mass.  The  instrument 
must,  of  course,  be  used  cautiously.  The  uterine  tissues  above 
the  base  of  the  tumour  are  then  cut  out  by  incisions,  with  the 
scissors  directed  upwards  and  towards  the  cer"sdcal  canal  or 
uterine  cavdty.  The  depth  of  these  incisions  will  depend  upon 
the  extent  of  suspicious  tissue  discovered  in  the  individual  case. 
When  a  clean  funnel-shaped  ca\ity  has  thus  been  cut  out  of  the 
cervix  and  lower  part  of  the  uterus,  it  is  chied  with  sponges  and 
plugged  with  cotton-wool  carefully  soaked  and  squeezed  after 
immersion  in  a  1  in  40  solution  of  carbolic  acid  containing  1  in 
12  parts  of  powdered  alum.  The  vagina  is  plugged,  above  in 
the  same  manner,  below  Avith  aa'OoI  soaked  in  the  carbolic 
solution  without  alum. 

At  the  end  of  five  days  the  plug  is  removed,  and  the  cavity 
is  packed  Anth  wool  soaked  in  chloride  of  zinc  solution  (five 
drachms   to   the   ounce   of   distilled    water).      The   vagina  is 


CAUSTICS KNIFE    AND    SCISSORS ELECTROLYSIS.  333 

plugged  above  witli  wadding  soaked  in  a  solution  of  bicar- 
bonate of  soda.  The  caustic  plug  is  removed  from  tbe  cavitv 
five  days  later.  The  ca\dty  will  be  lined  by  a  slough,  which 
often  comes  away  entire  on  traction.  The  subjacent  tissues 
will  gradually  heal  by  granulations. 

This  operation  is  objectionable  in  several  respects.  The 
inexperienced  will  find  it  difficult  to  cut  upwards  in  the  dark 
through  the  uterine  tissue.  A  strong  mineral  caustic,  when 
appHed  in  this  manner  to  uterine  tissue  above  the  cervix, 
produces  frightful  agony,  which  the  free  administration  of 
opiates  can  but  imperfectly  palliate;  it  may  also  bring  away 
too  much  of  the  uterine  tissue  and  damage  adjacent  parts. 
This  occmTed,  at  least  once,  in  the  practice  of  Dr.  Marion  Sims 
himself.*  In  this  case  the  greater  part  of  the  interior  of  the 
uterus,  including  about  half  the  thickness  of  its  muscular 
portion,  came  away.     The  patient  lived  for  a  few  months. 

Amputation  of  the  Vaginal  Portion  of  the  Cervix 
by  the  Knife  and  Scissors. — This  operation  is  advocated 
by  Schroder  and  Marckwald.  It  is  only  advisable,  in  cases  of 
cancer,  when  but  a  small  extent  of  the  lower  part  of  the  vaginal 
portion  of  the  cervix  is  involved  in  malignant  disease.  The 
operation  will  be  described  in  connection  with  the  subject  of 
amputation  of  the  cervix  for  hypertroph}'. 

Electrolysis  in  Cancer  of  the  Cervix.  —  When  an 
operation  for  cancer  of  the  cervix  is  not  deemed  advisable, 
or  vnll  not  be  submitted  to,  great  benefit  and  relief  of  pain, 
with  prolongation  of  life,  can  be  obtained  by  destruction  of  the 
cancerous  gro^\i;h  by  electrolysis.     For  this  pui'pose  an  electrode 


Fig.  125.— Zinc  Electiiode  fou  the  Decomposition  of  Caxceuous  Tissue. 

(Fig.  125),  composed  of  a  broad  piece  of  zinc,  is  connected  with 
the  positive  pole  of  a  constant  cm'rent  battery ;  the  negative 
electrode,  in  the  form  of  a  metal  and  amadou  pad,  being  placed 

*  See  specimen  4,600,  Museum  E.  C.  ,S.,  Pathological  Series.  The  case  was  a 
patient  of  that  distinguished  specialist,  who  presented  the  specimen  to  the  donor, 
Sir  Spencer  AVells. 


334  AMPUTATION    OF    THE    CERVIX. 

on  some  indifferent  part  of  the  body.  When  the  circuit  is 
•closed,  decomposition  of  the  diseased  tissue  takes  place  b}^  a 
formation  of  chloride  of  zinc  around  the  positive  electrode. 
This  has  an  advantage  over  destruction  of  tissue  by  ordinary 
chloride  of  zinc  or  the  actual  cautery,  inasmuch  as  the  action 
<3an  be  localized  and  arrested  at  pleasure,  and  the  amount  of  the 
destruction  to  be  wished  for  is  entirely  under  the  control  of  the 
operator,  the  pain  ceasing  immediate!}"  the  current  is  cut  off. 

The  partial  destruction  of  a  cancerous  surface  on  the  cervix, 
by  electricity  or  caustics,  will  not  fail  to  give  great  relief  to  the 
patient,  provided  that  the  sloughy  and  ulcerating  part  of  the 
disease  is  thoroughly  destroj^ed. 

Primary  Hypertrophy,  or  Elongation  of  the  Cervix. 
— This  remarkable  condition  consists  of  an  extreme  elongation 
of  the  cervix,  which  becomes  so  long  as  to  reach  the  vulva  or 
even  to  protrude  beyond  the  labia.  In  other  respects  the 
cervix  remains  healthy,  and  the  uterus  is  not  displaced.  Thus 
the  fornices  of  the  vagina  are  found,  on  digital  exploration, 
to  exist  un effaced  and  to  lie  at  their  usual  high  level.  The 
fundus  uteri  also  occupies  its  natiu-al  position,  and  on  passing 
the  sound  no  displacement  can  be  detected,  though  it  will  pass 
four,  five,  or  more  inches  up  the  cervical  and  uterine  cavity 
before  it  reaches  the  fundus.  This  gain  in  length  ^^dll  be 
entirely  due  to  increase  in  the  length  of  the  canal  of  the 
elongated  vaginal  part  of  the  cervix ;  on  rectal  examination 
(see  page  6^)),  the  supra- vaginal  portion  and  the  body  of 
uterus  will  be  found  to  occup}^  their  normal  position. 

This  condition  must  be  distinguished  from  certain  other 
riffections.  It  differs  entirely  from  liypertrophy,  or  apparent 
hypertrophy  of  the  cervix,  due  to  inflammation  or  oedema. 
It  is  quite  a  different  condition  from  laceration  of  the  cervix 
with  hj'pertrophy  and  true  or  supposed  ectropion.  Lastly,  it 
must  never  be  confounded  with  the  secondary  elongation, 
or  hypertrophy  of  the  cervix,  which  occm's  in  prolapsus 
uteri.  In  this  last  affection,  the  relations  of  the  vaginal 
fornices  and  the  body  of  the  uterus  will  be  markedly 
abnormal. 

Hypertrophy  of  the  cervix  is  probably  congenital.  I  have 
seen   tliis   condition   in  women  who    have   consulted   me    for 


AMPUTATION    OF    ELONGATED    CERVIX.  335 

other  maladies,  and  it  appeared  to  cause  no  pain  or  dis- 
comfort. On  the  other  hand,  it  may  give  rise  to  trouble- 
some symptoms.  The  protruding  cervix  sometimes  becomes 
excoriated  or  even  ulcerated,  there  may  be  much  bearing- 
down  pain,  and  locomotion  may  even  be  impeded.  In 
married  life  hypertrophy  of  the  cervix  is  an  obvious  source 
of  inconvenience. 

Treatment. — The  surgeon  should  not  attempt  to  interfere 
Avith  this  condition  until  he  has  not  only  duly  considered  the 
circumstances  of  the  case,  but  also  studied  the  experience 
of  authorities,  which  may  be  found  recorded  in  systematic 
text-books.  Most  of  these  authorities  admit  that  amputation 
is  allowable  and  advisable  in  cases  of  primary  hypertrophy 
when  it  is  a  cause  of  sterility  or  of  great  inconvenience. 
Amputation  may  then  be  perfoimed  either  by  the  ecraseur, 
the  galvano-cautery,  or  by  special  plastic  proceedings  where 
the  knife,  scissors,  and  needle  are  employed. 

Amputation  hy  ^crawur. — This  operation  has  been  already 
described  (page  328).  It  is  of  questionable  merit  in  cases  of 
hypertrophy,  as  non-cancerous  tissues  are  removed,  and  it 
is  important  that  the  structures  left  behind  should  be  not 
only  healthy  from  the  first  but  should,  in  healing,  assume 
a  condition  closely  resembling  that  of  a  natui'ally  formed 
cervix.     After  a  crushing  operation,  this  is  impossible. 

Amputation  hy  Galrano-Cautery  (see  page  325). — Thomas, 
Byrne  of  Brooklyn,  and  others,  speak  highly  of  this  method, 
and  Thorburn  considers  that  it  should  be  adopted  by  the 
general  practitioner.  It  is  preferable,  in  every  respect,  to  the 
ecrasem',  but  can  hardly  restore  the  parts  to  a  natural  condition 
fit  to  discharge  active  functions. 

Amputation  combined  with  Plastic  OperatJona. — Schroder* 
considers  that  there  is  scarcely  any  organ  more  fitted  for 
plastic  operations  than  the  cervix.  He  has  entirely  rejected 
the  ecraseur  and  galvano-cautery  in  favour  of  the  practice 
of  cutting  out  a  portion  of  the  cervix  with  a  lance-shaped 
knife  and  using  sutures.  In  hypertrophy  of  the  cervix  an 
operation   of    this   kind   is   probably   the   best   which  can   be 

*  Zur  Tcchiiik  dcr 'jplastiscltcii  Operational  am  Cervix  Uteri.  Charite  Annalen 
V.  Jahrgang. 


336  AMPUTATION    OF    THE    CER^■IX. 

adopted.  Such  a  proceeding,  liowever,  demands  dexterity 
and  experience.  The  manipulations  are,  for  the  most  part, 
difficult,  and  the  risk  of  haemorrhage  considerable.  With 
the  advantage  of  some  experience  in  plastic  and  uterine 
sm'gery,  however,  a  surgeon  may  be  justified  in  operating 
in  this  manner  in  a  suitable  case  of  elongation  of  the  cervix. 

Varietic^i  of  Aiiqmtation  of  tJtc  Cervix  hy  the  Knife. — I  shall 
not  describe  the  simple  circidar  amputation  of  the  cervix, 
with  cauterization  of  the  raw  sm-face  of  the  stump.  This 
proceeding  entails  risks  of  haemorrhage  dimng  the  operation, 
and  the  certainty  of  a  subsequent  formation  of  dense  cica- 
tricial tissue,  with  constant  tendency  to  atresia  of  the  eer\dcal 
canal.  The  knife  should  be  used  as  a  preliminary  to  plastic 
measm*es,  else  the  galvano- cautery  is  preferable.  The  plastic 
measm'es  in  question  may  be  divided  into  thi*ee  varieties. 

1. — Si)n>i''  Ainpufatloii. — The  patient  is  placed  in  the  semi- 
prone  position,  and  the  blade  of  a  Sims'  speculum  is  passed 
along  the  posterior  vaginal  wall.  After  the  vagina  has  been 
well  washed  out  with  an  antiseptic  solution,  the  cervix 
is  drawn  a  little  downwards  by  a  volsella ;  a  stout  india- 
rubber  ring  is  slipped  over  the  cer-vix  till  it  rests  close  to  the 
vaginal  fornices.  The  cervix  is  then  split  by  a  scalpel  on 
each  side,  beginning  at  one  extremity  of  the  os  and  carrying 
the  incision  upwards  to  about  an  inch  from  the  vault  of  the 
vagina.  The  incision  must  not  be  carried  too  high,  as  the 
relations  of  the  parts  are  often  altered  in  these  cases  of 
elongation  of  the  cervix,  and  it  would  be  dangerous  to  cut 
into  the  vascular  suiToundings  of  the  supra-vaginal  part  of 
the  cer^-ix.  An  anterior  and  posterior  flap  are  thus  formed ; 
these  are  cut  thi'ough  horizontally  at  their  upper  limits. 
An  oval  raw  sm*face  will  be  left,  with  the  cervical  canal  in 
the  centre,  and  the  cut  edge  of  the  mucous  membrane  at  the 
circumference.  "  This  operation  is  often  a  bloody  one,"  says 
Dr.  Gralliard  Thomas.  Though  the  cautery  or  styptics  may 
check  the  haemorrhage,  the}'  will  interfere  with  the  union  of 
the  wound.  It  is,  therefore,  better  to  seize  any  bleeding 
points  with  light  pressure-forceps  such  as  Pean's  (see  page 
95),  and  to  leave  the  instruments  on  for  a  few  minutes,  or 
the  vessels  may  be  twisted. 


AMPUTATION    OF    ELONGATED    CERVIX.  837 

The  second  part  of  the  operation  consists  of  plastic  pro- 
ceedings. About  four  silver-wire  sutui'es  are  passed  thi-ough 
the  vaginal  mucous  membrane,  so  as  to  stitch  it  over  the 
raw  surface.      This  is  the  principle  of  Sims'  amputation. 

The  edge  of  the  mucous  membrane  is  seized  with  tenaculum- 
forceps,  anteriorly,"  near  one  extremity  of  the  cervix,  and  a 
silver  wire  is  passed  through  it,  about  one-eighth  of  an  inch 
from  the  free  border,  by  means  of  a  short,  stout,  curved 
needle  mounted  on  a  holder.  The  wire  is  drawn  across  the 
raw  surface  of  the  cervix,  not  penetrating  the  tissues,  and 
through  the  mucous  membrane  posteriorly.  One  or  two  more 
sutures  are  passed  through  the  edges  of  the  mucous  membrane, 
anteriorly  and  posteriorly,  crossing  the  stump,  on  the  same 
si^de  of  the  canal  of  the  cervix.  The  suturing  process  is 
repeated  on  the  other  side,  the  last  suture  being  inserted 
near  the  opposite  extremity  to  that  near  to  which  the  first 
was  passed. 

The  anterior  and  posterior  ends  of  each  of  the  sutm-es  are 
twisted  so  that  the  mucous  membrane  is  brought  over  the 
raw  surface  of  the  stump,  excepting  near  the  cervix.  Here 
the  sm-face  will  heal  by  granulation.  The  india-rubber  ring 
is,  lastly,  cut  slowly  through.  Grreat  care  must  be  taken  to 
pass  a  sound  frequently  for  many  months  after  the  operation, 
lest  atresia  should  occur.  The  patient  must  remain  in  bed 
for  a  week  at  least ;  at  the  end  of  ten  days  the  sutures 
should  be  removed.  The  vagina,  in  the  meantime,  is  kept 
clean  by  means  of  antiseptic  injections,  morning  and  evening. 
]Iegar''s  Amjmfation. — In  this  operation  a  circular  ampu- 
tation is  performed,  as  in  the  preceding.  The  mucous 
membrane  of  the  outer  side  of  the  cervix  is  then  united  to 
that  lining  the  cervical  canal,  both  being  brought  over  the 
raw  surface  of  the  stump.  About  eight  sutures  will  be 
required ;  they  must  radiate  from  the  canal  of  the  cervix,  and 
pass  not  over,  but  through  the  cervical  tissues. 

2I(irc1iicaI(Vs  and  Sinipson^s  Amputations. — Simon,  Marckwald, 
and  Schroder  have  practised  and  advocated  a  very  ingenious 
method  of  removing  part  of  the  cervix  by  a  flap  amj)utation, 
with  wedge-shaped  excision  of  the  lips  separately,  and  union 
of  the  mucous  membranes,  as  in  Hegar's  amputation,  over  each 

z 


338  AMPUTATION    OF    THE    CERVIX. 

lip  which  remains.  Dr.  A.  E,.  Simpson  has  modified  the 
method.  This  amputation  should  not,  however,  be  attemj^ted 
hv  any  who  have  not  enjoyed  the  advantage  of  long  experience, 
personal  and  indirect,  in  operations  on  the  cervix.  A  good 
description  of  Dr.  Simpson's  modification  will  be  found  in 
i)rs.  Hart  and  Barbour's  Manual  of  Gijiu^ology,  third  edition, 
page  271. 

Finally,  the  inexperienced  should  not  think  of  amputating 
a  cervix  that  has  undergone  hypertrophy  in  association  with 
prolapsus  uteri.  Few,  if  any,  specialists  now  recommend  ampu- 
tation of  a  cervix  subject  to  the  chronic  changes  which  may 
follow  laceration. 

Atresia  of  the  Cervix. — This  affection,  when  sufficient  to 
cause  retention  of  menses  in  the  uterine  cavity,  is  always  serious. 
Even  when  the  cervix  is  forced  open  by  the  sound  in  the  coui"se 
of  an  examination  for  an  undiagnosed  uterine  swelling,  and 
treacly  blood  begins  to  flow  away,  the  sm'geon  should  at  once 
take  great  precautions.  He  must  on  no  account  press  upon  the 
fundus  to  hasten  the  escape  of  the  retained  fluid,  nor  must  he 
throw  up  injections  of  any  kind.  The  patient  must  be  put  to 
bed  as  soon  as  possible,  and  treated  precisely  as  though  a  cou- 
genitally  closed  hymen  or  vaginal  septum  had  been  laid  open. 
The  treatment  of  such  cases,  and  the  dangers  which  smTOund 
them  during  and  after  operation,  Avill  be  presently  described. 

Breisky's  Operation. — The  successful  treatment  of  more 
.  severe  forms  of  atresia  of  the  cervix  requii'es  long  experience  in 
uterine  diseases.  There  is  always  much  difficulty  and  danger  in 
dissecting  a  new  cer^dcal  canal,  and  the  parts  above  it  may  be 
malformed.  Breisky  has  operated  in  seven  cases  of  retention  of 
menses  from  atresia  of  the  cervix  with  deficiency  of  the  vagina. 
He  dissects  between  the  bladder  and  rectum,  in  the  manner 
which  will  be  described  in  the  account  of  the  operation  for 
deficiency  of  the  vagina,  and  opens  the  cervix  by  means  of  a 
special  sharp-edged  trocar  and  cannula.  He  then  keeps  the 
trocar-wound  dilated,  as  the  retained  fluid  escapes  through  the 
cannula  by  the  aid  of  s[.ecial  long-handled  forceps,  with  long 
smooth  blades  which  are  slipped  along  each  side  of  the  cannula. 
The  latter  is  withdrawn  when  the  fluid  has  ceased  to  flow,  and 
the  nozzle  of  a  tube  is  then  inserted  into  the  cervix  between  the 


OPERATIONS    FOR   ATRESIA    AND    LACERATION    OF    CERVIX.    339 

blades  of  the  forceps.  A  tube  is  fitted  to  the  nozzle,  and  the 
uterine  cavity  is  syringed  out ;  the  tube  is  constructed  with  two 
channels,  so  as  to  conduct  away  the  return-current. 

This  operation,  as  may  be  judged  from  the  above  brief 
description,  is  exceedingly  difficult  from  beginning  to  end. 
Breisky  lays  great  stress  on  the  importance  of  washing  out  the 
retained  menses.  This  proceeding,  as  will  be  explained  in  the 
chapter  on  Atresia  of  the  Yulva  and  Vagina,  is  contrary  to  newer 
principles  which  have  at  least  met  with  success  in  the  treat- 
ment of  so-called  imperforate  hymen.  He  admits  that  the 
tendency  of  the  parts  to  contract  is,  as  might  be  expected,  very 
great.  A  full  account  of  his  operation  will  be  found  in  his 
Krankheiten  der  Vagina,  edition  of  1886,  in  Billroth  and 
Luecke's  Deutsche  Chirurgie  series. 

Operations  for  Laceration  of  the  Cervix  Uteri. — The 
treatment  of  lacerations  of  the  cervix  by  a  plastic  operation  has 
been  strongly  advocated  by  Emmet,  Fallen,  Thomas,  Breisky, 
and  several  other  American  and  Continental  authorities,  and 
recommended  to  a  less  extent  by  Dr.  Playfair.  The  most 
important  argument  in  favour  of  operation  is  the  theory  that 
a  laceration  may  become  the  seat  of  epithelioma.  That  this 
may  happen  there  can  be  no  doubt,  but  the  careful  scrutiny 
of  some  painstaking  pathologist  is  yet  needed,  to  trace  the 
relation  of  cause,  effect,  and  coincidence  in  any  conditions  of  the 
cervix  found  in  association  with  malignant  disease.  Chronic 
discharges,  subinvolution,  displacements,  and,  lastly,  all  kinds 
of  general  symptoms,  have  been  attributed  to  the  effects  of 
laceration  of  the  cervix. 

In  common  fairness.  Dr.  Emmet's  arguments  in  his  Principles 
and  Practice  of  Gj/meeologi/  should  be  studied,  and  when  the 
surgeon  is  induced  to  operate,  he  must  remember  all  that  distin- 
guished American's  directions  as  to  denuding  the  angles  of  the 
flaps  thoroughly,  clearing  away  cicatricial  tissue,  and  avoiding 
injury  to  the  pelvic  connective  tissue  near  the  cervix.  The 
intending  operator  should  also  read  Dr.  Playf air's  "  Notes  on 
Trachelo-raphe,  or  Emmet's  Operation,"  in  the  Transactions  of 
the  Obstetrical  Society  of  London,  vol.  xxiv.,  where  the  operation 
is  temperately  advocated.  Particular  attention  must  be  paid 
to  Dr.  Matthews  Duncan's  remarks  in  the  discussion   which 


340  THE    OPERATION    OF    TRACHELORRHAPHY. 

followed  the  reading  of  this  memoir  {ihid,  page  71)  :  He  "had 
seen  the  most  exaggerated  laceration  of  the  cervix  interfere  in 
no  degree  with  health,  comfort,  and  fertility."  Dr.  Duncan 
also  noted  that  the  so-called  ectropion  may  in  many  cases  be 
purely  artificial,  and  simply  due  to  the  pressure  of  some  part 
of  a  speculum. 

Nevertheless,  the  surgeon  may  meet  with  cases  where,  after 
careful  watching,  he  may  feel  justified  in  attributing  severe 
local  sjauptoms  to  a  laceration  of  the  cervix.  In  no  case  must 
he  operate  should  any  of  the  physical  signs  of  cellulitis  (para- 
metritis) be  present.  The  laceration  should  always  be  explored 
Avith  the  assistance  of  the  volsella  (page  76),  as  well  as  by 
means  of  the  finger  and  speculum. 

The  Operation  of  Trachelorrhaphy* :  Prepamtonj 
Treatment. — Before  this  operation  is  performed,  the  surgeon 
must  first  make  sure  that  any  local  complication,  such  as  pelvic 
cellulitis,  is  cured.  For  about  a  week,  hot- water  injections 
should  be  thrown  up  night  and  morning.  It  is  especially 
important  to  remedy  any  uterine  displacement.  The  uterus 
must  be  replaced  and  kept  in  position  by  means  of  a  properly 
adjusted  Hodge's  pessary.  After  each  injection  a  cotton-wool 
plug,  with  a  piece  of  string  attached  to  it,  dipped  in  glycerine, 
or  in  glycerine  of  tannic  acid,  should  be  pressed  against  the 
cervix,  and  removed  before  the  application  of  the  next  injection. 
When  there  is  marked  ectropion  of  the  surface  of  the  lacera- 
tion, with  cystic  degeneration  of  the  mucous  follicles,  the 
affected  surface  should  be  scarified  frequently,  and  painted 
with  glycerine  and  iodine  till  the  size  of  the  flaj)s  is  much 
reduced.  After  each  scarification,  a  pledget  of  wool  dipped 
in  glycerine  may  be  packed  against  the  cervix,  so  as  to 
press  the  lacerated  flaps  together.  After  a  week  or  two  of 
the  above  treatment  the  patient  will  be  ready  for  oj^eration, 
provided  that  no  tenderness  or  hardness  can  be  felt  thi'ough 
the  vaginal  walls  on  either  side  of  the  cervix. 

Position  duriny  Operation. — Emmet  prefers  to  place  the 
patient  in  the  semi-prone  position  (see  page  57),  but  he 
admits   that  the  operation  can  sometimes  be  performed  with 

*  III  this  description  I  have  chiefly  followed  the  directions  given  in  Dr. 
Emmet's  Principles  and  Practice  of  Gynecology,  third  edition,  1885. 


POSITION    OF    PATIENT THE    SPECULUM.  341 

the  patient  on  her  back,  when  the  vaginal  outlet  is  large,  since 
the  uterus  is  then  so  low  that  it  can  be  readily  drawn  outside, 
and  returned  after  the  operation.  Most  English  operators 
prefer  the  lithotomy  position.  .Formerly,  Dr.  Emmet  used  to 
constrict  the  cervix  above  the  laceration  by  means  of  a  uterine 
tourniquet,  which  resembled  a  chain  ecraseur,  excepting  that 
the  chain  was  replaced  by  a  loop  of  watch- sjaring.  This  he 
now  employs  solely  in  extreme  cases  where  the  tissues  of  the 
cervix  are  very  soft  and  liable  to  bleed.  In  ordinary  cases, 
an  injection  of  water  heated  to  about  110°,  thrown  up  just 
before  the  operation,  will  be  sufficient  to  prevent  severe  hsemor- 
rhage.  Hart  and  Barbour  recommend  a  stout  india-rubber 
umbrella-ring  to  be  slipped  on  to  the  upper  part  of  the  cervix 
over  a  volsella.  At  the  end  of  the  operation  it  is  notched  with 
scissors,  so  as  to  be  gradually  slackened  before  it  is  cut  through. 


Fig.  126. — Shop.t  Speculum  foii  Trachelorrhaphy.     [Percy  Boulton.) 

The  Speculum  in  Trachelorrluiphij. — When  the  cervix  can 
readily  be  drawn  down,  this  operation  is  not  very  difficult ; 
when  it  can  not,  neither  the  dissecting  up  of  raw  surface  nor  the 
introduction  of  sutures  can  be  easily  effected.  Dr.  Boulton  has 
devised  a  special  short  speculum  (Fig.  126),  made  of  metal, 
which  he  has  found  to  be  very  convenient  for  the  first  stage  of 
the  operation,  when  the  raw  surfaces  are  formed.  It  dispenses 
with  a  multiplicity  of  assistants,  it  steadies  the  uterus  and 
prevents  excessive  dragging  on  the  uterine  ligaments,  and  can  be 
kept  in  place  by  the  pressure  of  one  assistant's  thumb  against 
its  edge.     When  the  sutures  are  being  inserted,  this  instrument 


342 


THE    OPERATION    OF    TRACHELORRHAPHY. 


should  be  remoyed,  and  a  blade  of  Sims'  speculum  is  slipped 
along  tbe  posterior  vaginal  wall.  Dr.  Emmet  recommends  great 
caution  in  handling  tbe  cervix  during  operation,  especially  when 
any  manipulation  involves  dragging-down  of  tbe  uterus.  As  a 
certain  amount  of  celkilitis  exists  in  many  cases,  traction  may 
disturb  inflamed  tissue  and  cause  a  possibly  fatal,  and  certainly 
misebievous,  extension  of  tbe  morbid  process. 

Traclielorrliaphil  for  Bilcderal  Laceration  :  Denudation  of 
the  Flaps. — A  tenaculum  witb  a  sbort  cm-ve,  and  as  stout 
as  possible,  is  fixed  on  to  one  flap,  and  another  on  to  its 
fellow.     The  pair  are  then  approximated.     The  operator  can 


Fig.  127. — Lacerated  Cervix  after  Dexudatiox, 

As  seen  from  one  side  after  the  introduction  of  the  sutures  for  the  closure 
of  the  denuded  surface  •which  lies  on  that  side.  The  flaps  are  somewhat 
approximated. 

then  judge  if  tbe  flaps  wi]l  lie  in  connect  apposition  after 
simple  denuding  of  their  sui'faces.  If  this  be  the  case,  then, 
it  being  supposed  that  the  laceration  is  bilateral,  the  flaps  are 
opened  out  and  the  lacerated  sm-faces  well  exposed.  The 
surgeon,  fixing  one  flap  with  the  tenaculum  which  he  holds  in 
his  left  hand,  then  cuts  away  a  strip  of  mucous  membrane,  with 
a  little  of  the  subjacent  tissue.  The  simplest  and  safest  method, 
perhaps,  of  dissecting  up  the  flaps  (as  practised  by  Dr.  Percy 
Boulton)  is  to  thrust  the  point  of  a  small  long-handled  scalpel 
carefully  into  the  outer  aspect  of  the  apex  of  the  angle  between 
the  fla^is  (Fig.  127,  a),  so  as  to  raise  the  mucous  membrane. 


DENUDATION    OF    THE    FLAPS. 


343 


By  tiu-ning  the  blade  towards  tke  flap  to  be  first  denuded,  a 
strip  of  the  desired  breadth  is  raised  ;  the  remainder  may  be  cut 
away  with  scissors,  and  the  corresponding  side  of  the  opposite 
flap  is  then  denuded.  In  whatever  manner  this  process  is 
carried  out,  two  precautions  are  to  be  taken  whenever  any 
cutting  instrument  is  used  near  the  angle  between  the  flaps. 
Firstly,  the  tissues  must  be  thoroughly  vivified,  else  union  of 
the  deepest  part  of  the  surfaces  to  be  drawn  into  apposition 
will  not  take  place.  Secondly,  care  must  be  taken  not  to  cut 
deeply  at  the  outer  extremity  of  the  angle,  which  lies  close  to 


Fig.  128.- -Lacerated  Cervix  after  Dexudatiox, 

As  seen  from  below  after  the  introduction  of  the  sutures  for  the  closuie  of 
one  of  the  denuded  surfaces.  The  figures  indicate  tlie  end  of  the  higlier  sutures. 
1  1  corresponds  to  e  d,  b  c,  in  the  preceding  figure.  The  lowest  thread  is  marked 
A  a,  B  b.     {Emmet.)     The  flaps  are  widely  parted. 


the  reflection  of  the  vaginal  mucous  membrane,  else  the  cii"cular 
artery  (see  Fig.  12,  and  page  41)  may  be  wounded. 

The  process  of  denudation  is  now  repeated  on  the  other  side 
of  the  flaps.  A  broad  tract  is  left  undenuded  between  these 
vivified  strips  (Fig.  128).  This  tract  will  form  the  cervical 
canal  and  the  external  os  when  the  operation  is  completed.  It 
must  be  left  widest  towards  the  outer  extremities  of  the  flaps. 


344  THE    OPERATION    OF    TRACHELORRHAPHY. 

but  after  healing,  the  new  canal,  at  first  trumpet-shaped,  will 
become  uniform  in  diameter.  The  siu-faces  are  now  cleaned  by 
mounted  sponges  pressed  against  them  till  haemorrhage  has 
ceased. 

Application  of  the  Stif tires. — The  flaps  are  next  approximated 
by  the  tenacula,  so  that  the  operator  can  make  sure  that  they 
A\'ill  then  lie  easily  in  apposition.  If  this  be  the  ease,  so  that 
no  further  trimming  is  required,  the  sutiu-es  are  now  applied. 
This  is  a  difficult  process,  owing  to  the  position  of  the  flaps  and 
the  extreme  toughness  of  the  uterine  tissue.  A  Sims'  speculum 
is  passed  along  the  posterior  wall  of  the  vagina.  The  sm-geon 
then  takes  in  his  hand  a  needle  mounted  on  a  handle,  and 
eyed  near  the  point,  where  it  is  very  slightly  curved,  or,  rather, 
bent  at  an  obtuse  angle.  This  needle  will  be  described  in  the 
chapter  on  Yesico-vaginal  Fistula.  For  trachelorrhaphy  it  must 
be  very  stout,  as  the  uterine  tissue  is  tough.  Any  clumsiness  in 
handling  a  needle  as  it  is  forced  through  the  parts  which  it  is 
made  to  transfix  may  cause  it  to  snap.  The  flap  being  steadied 
with  a  tenaculum,  the  point  of  the  needle  is  entered  (at  h  in 
Fig.  127)  about  one-eighth  of  an  inch  external  to  the  raw 
surface,  close  to  the  outer  aspect  of  the  angle  between  the  flaj^s 
(a),  and  pushed  inwards  under  the  raw  sm-face  till  it  emerges 
(at  x)  close  to  (not  beyond)  its  inner  border.  Then  a  fine  silver 
wire  is  threaded  on  the  needle,  which  is  withdrawn  till  one  end 
of  the  ware  (c)  is  j)ulled  well  through  and  beyond  the  site  of 
operation.  The  needle  is  then  entered  at  d,  a  point  opposite  to 
b,  near  the  angle,  and  passed  imder  the  flap  (emerging  at  //) 
in  the  same  manner.  The  other  end  of  the  same  wire  is 
threaded  on  to  it ;  then  the  needle  is  -withdrawn  till  that  end 
of  the  wire  (e)  is  pulled  through.  Three  or  fom*  more  wires 
are  then  introduced  in  the  same  way  lower  down  the  flaj)S. 
They  will  he  as  shown  in  Fig.  127 ;  in  Fig.  128  (from  Dr. 
Emmet's  work)  their  position,  as  seen  from  the  inner  aspect 
of  the  flaps,  is  demonstrated. 

A  stout  curved  Hagedom's  needle  (page  116)  may  be  used 
for  the  introduction  of  sutures.  A  beginner,  however,  will  not 
find  this  needle  and  its  holder  easy  to  work  in  trachelorrhai:)hy. 

The  sutures  are,  lastly,  drawn  together  after  the  flaps  have 
been  well  cleaned  by  means  of  sponges.     They  must  be  care- 


AFTER-TREATMENT    AND    REMOVAL    OF    SUTURES.  345 

fully  twisted  and  cut  off,  so  as  to  leave  the  ends  about  half  an 
inch  long.  These  cut  ends  are  then  bent  downwards,  against 
the  side  of  the  cervix,  where  they  will  produce  no  irritation. 

After-treatment. — Emmet  lays  great  stress  upon  after-treat- 
ment, and  to  the  rigorous  injunctions  which  he  enforces,  rather 
than  to  the  operation  which  he  advocates,  the  opponents  of  his 
theory  and  practice  attribute  his  success.  The  patient  is  con- 
fined to  bed  for  a  fortnight  or  more  after  the  operation,  lest  the 
flaps  should  separate.  Rest  in  the  horizontal  position  facilitates, 
in  Dr.  Emmet's  opinion,  the  necessary  decrease  in  the  size  of 
the  enlarged  uterus.  The  patient's  diet  need  not  be  restricted, 
and  the  bowels  should  not  be  allowed  to  remain  constipated. 
A  warm- water  injection  must  be  thrown  up  the  vagina  after 
catheterism  or  micturition,  to  avoid  irritation  of  the  wound 
through  urine  which  may  escape  into  the  vagina.  After  the 
second  day,  especially  if  there  be  much  discharge,  a  vaginal 
injection  of  tepid  water  should  be  given  night  and  morning. 

Removal  of  Sutures. — The  sutures  may  be  removed  on  the 
seventh  day.  "  When  the  patient  is  placed  on  the  left  side, 
and  the  cervix  has  been  brought  into  view  by  the  use  of  Sims' 
speculum,  the  lower  portion  of  the  loop  should  be  cut  close  to 
the  end  of  the  twist,  and  then  withdrawn.  Each  portion  of 
the  loop  will  then  bind  the  parts  together  until  it  has  been 
removed,  while,  if  we  should  cut  the  upper  part  and  make 
traction,  the  surfaces  would  be  drawn  asunder.  It  is  best  to 
remove  first  the  suture  nearest  to  the  vaginal  junction,  for,  if 
there  should  be  any  tendency  to  gape  in  the  line,  the  others  can 
be  left  for  several  days  longer,  so  that  the  ununited  portion  may 
heal  by  granulation  "  (Emmet).  Dr.  Boulton  prefers  to  leave 
the  sutures  alone  till  the  fourteenth  day,  as  they  appear  to 
cause  little,  if  any,  irritation. 

Emmet  insists  that  the  patient  shoidd  not  sit  up  in  bed  for 
ten  or  twelve  days  after  the  operation.  If  this  rule  be  neglected, 
a  portion  of  the  line  of  union  is  very  apt  to  separate.  "  More- 
over, to  get  up  would  expose  her  to  the  effects  of  cold,  and 
cellulitis,  if  it  has  existed,  is  likely  to  recur  on  a  slight  pro- 
vocation." Where  retroversion  of  the  uterus  exists,  a  pessary 
should  be  applied  when  the  patient  is  convalescent. 

Parotitis  has  occurred  during  convalescence  from  this  opera- 


346  THE    OPERATION    OF    TRACHELORRHAPHY. 

tion  in  at  least  two  cases — one  in  Dr.  Emmet's  experience  ;  the 
second,  where  there  had  been  much  hsemorrhage,  in  the  practice 
of  Dr.  Goodell.  The  latter  records  this  fact  in  a  contribution 
on  "  Inflammation  of  the  Parotid  Grland  following  Operations 
on  the  Female  Grenital  Organs,"  in  the  Transactions  of  the 
American.  Gi/)t(eeologicaI  Society,  vol.  x.,  1885. 

TraclielorrhapJnj  under  otlier  Conditio)is. — The  operation  has 
been  above  described  as  performed  when  some  time  has  elapsed 
since  the  labour  when  the  cervix  was  lacerated,  and  when  the 
laceration  is  bilateral  and  free  from  much  hypertrophy  of 
the  torn  surfaces,  or  formation  of  abundant  cicatricial  tissue. 
It  is,  however,  also  performed  ander  diiferent  conditions. 

Immediate  Trachehrrliaphy. — Dr.  Montrose  Fallen,  of  New 
York,  is  an  advocate  of  trachelorrhaphy  immediately  after 
labour.  He  asserts*  that,  when  the  laceration  is  positively 
diagnosed,  the  best  treatment  is  to  close  the  wound  in  the  cervix 
with  silver- wire  sutures.  This,  he  believes,  checks  haemorrhage, 
and  removes  a  serious  cause  of  subsequent  septicaemia.  The 
torn  edges  being  well  fitted  together,  and  the  wires  twisted 
sufficiently  tight,  no  suppurative  foci  remain,  and  no  raw 
sm-faces  are  left  exposed  to  absorb  septic  material  from  the 
lochia.  Of  course,  no  denudation  will  be  necessary ;  the  sur- 
faces ai-e  simply  washed  before  operation.  As  in  the  process  of 
healing  much  contraction  will  ensue,  the  wii-es  must  be  passed 
at  one-third  to  half  an  inch  from  the  margin  of  the  torn 
surfaces.  As  many  sutures  should  be  passed  as  are  absolutely 
necessary  to  prevent  any  gaping  of  the  wound,  so  that  the 
lochia  may  bathe  no  raw  surfaces.  The  vagina  is  washed  out 
^dth  antiseptic  solutions  every  six  or  eight  hours,  and  the 
sutures  are  removed  in  the  manner  above  described. 

Dr.  Fallen  and  other  operators,  chiefly  American,  claim  ex- 
cellent residts  from  tliis  practice.  It  has  not,  however,  met 
with  much  practical  approval  in  this  country. 

Operation  in  Cases  of  Ectropion. — At  the  onset  of  the 
operation,  it  may  be  found  that  the  flaps  cannot  be  api:)roxi- 
mated,  on  account  of  great  bulging  of  hypertrophied  tissue 
from  their  surfaces.     The  hypertrophied  tissues  must  then  be 

*  "On  the  Etiology  and  Treatment  of  Lacerations  of  the  Cervix  Uteri" 
(British  Medical  Journnl,  vol.  i.  1881.  p.  764). 


OPERATION    IN    CASES    OF    ECTROPION. 


34- 


cut  away  (Fig.  129),  in  such  a  manner  that  two  raw  surfaces 
can  he  approximated,  leaving  space  for  the  cervical  canal,  as 
hefore  (Figs.  129,  130). 

Management  of  Cicatricial  Tissue  in-  the  Fkq^s. — Next  to  the 
precaution  against  traction  involving  tissues  possibly  affected 
with  cellulitis  (see  page  342),  nothing  in  respect  to  trachelor- 
rhaphy is  more  important  for  the  surgeon  to  remember  than  the 
had  results  which  may  follow  any  neglect  to  remove  cicatricial 


Fig. 


129. — Cicatricial  Hypeiitro- 
phy  after  laceration. 


The  lines  A  B,  C  D  indicate  the  por- 
tion to  be  removed.     [Emmet. ) 


Fig.  1-30. — Horizontal  Plane  of 
Cervix. 

From  same  case  as  Fig.  129. 
The  hypertrophied  tissue  is  indicated 
by  A,  B,  C,  D,  and  is  to  be  removed  to 
the  bottom  of  the  laceration,  along  the 
dotted  lines,  so  that  the  surfaces  A  and 
B,  C  and  D  can  be  united  by  sutures 
after  A  C,  B  D  have  been  denuded. 
[Emmet.) 


tissue.  This  accident  is  the  result  of  not  thoroughly  denuding 
the  necessary  surfaces  along  the  angle  between  the  flaps.  In 
this  angle  granulations  are  often  observed,  representing  a 
growth  of  cicatricial  tissue  beginning  to  fill  up  the  flap.  Should 
these  granulations  be  left  untouched,  or  only  pared  superficially 
along  the  line  T  in  Fig.  131,  the  flaps  cannot  be  properly 
closed,  just  as  the  sides  of  two  contiguous  fingers  cannot  be 
thoroughly  approximated  when  a  reel  is  kept  in  the  angle 
between  them.  Hence,  a  Y-shaped  wedge  of  this  tissue  must 
be  cut  out,  and  the  sutures  must  also  be  carefully  applied  to  the 


348 


THE    OPERATION    OF    TRACHELORRHAPHY. 


part  of  the  flap  whence  it  was  excised.  This  must  be  done  on 
both  sides — that  is  to  say,  a  wedge  is  cut  out  from  the  angle  in 
each  of  the  vivified  surfaces.  In  so  doing,  the  sm'geon  must  be 
careful  not  to  cut  deeply  through  the  tissues  external  to  the 
angle,  lest  the  circular  artery  be  endangered  (see  page  343). 
TJnilcderal  Lacerations. — In  this  variety  there  will  simply  be 
but  one  strip  of  mucous  membrane  to  sew  up.  Operation, 
under  these  circumstances,  is  by  no  means  easier  than  when 
the  laceration  is  bilateral.  It  is  difficult  to  cut  along  the 
angle  and  the  inner  side  of  the  flaps.  Dr.  Boulton's  practice 
of  thrusting  a  scalpel  through  the  outer  aspect  of  the  angle,  so 
as  to  free  the  tissues  there,  and  then  finishing  the  dissection 


Fig.  131. — Cicatricial  Plug  in  a  Lacerated  Cervix.     {Emmet) 
C  represents  the  plug,  T  the  surface  of  the  laceration. 


with  scissors  (page  342) ,  may  bo  very  advantageously  applied  in 
these  cases. 

Multiple  Lacerations. — It  is  useless  to  pare  all  the  edges  of 
multiple  lacerations  and  to  unite  them  with  sutiu'es,  as  this 
proceeding  would  involve  traction  in  opposite  directions,  tending 
to  part  the  apposed  surfaces  and  to  tear  out  the  stitches.  As  a 
rule,  two  of  the  lacerations  are  tolerably  close  together.  In  such 
a  ease  the  tissue  between  them  may  be  cut  out  in  the  form  of 
a  wedge,  and  the  surfaces  left  facing  each  other  are  denuded 
(Fig.  132). 


AMPUTATION    OF    A    LACERATED    CERVIX.  349 

Amputation  of  Lacerated  Cervix. — When  abundant 
cicatricial  tissue  or  extensive  cystic  degeneration  has  taken 
place  in  the  region  of  a  laceration,  the  advocates  of  trache- 


FiG.  132. — Bifid  Laceration  of  the  Cervix.     [Emmet.) 

The  portion  between  the  two  fissures  would,  according  to  Dr.  Emmet,  require 

excision. 

lorrhaphy  contend  that  amputation  of  one  lip  or  of  the  entire 
cervix  may  be  needed  to  prevent  the  chance  of  malignant 
degeneration.  Emmet  has  amputated  the  anterior  lip  with 
scissors,  removing  all  the  morbid  tissue.  The  stump  was 
covered  by  drawing  the  vaginal  tissue  over  it  from  each  side, 
and  securing  it  by  six  interrupted  silver  sutures.  Most  British 
gynaecologists  are  averse  to  these  extreme  measures. 


350 


CHAPTEE  XIII. 

OPERATIVE  TREATMEXT  OF  EXTRA-UTERIXE  PREGXAXCY. 

Operative  Treatment  of  Extra-uterine  Pregnancy. 

— The  principles  of  palliative  and  expectant  treatment  of  extra- 
nterine  pregnancy  are  laid  down  in  systematic  text-books  on  ob- 
stetrics. Works  of  tbat  class  contain  descriptions  of  incomplete 
operative  measures — that  is  to  say,  operative  proceedings  where 
the  foetus  is  not  removed ;  in  contradistinction  to  operations, 
which  I  shall  describe  in  full,  where  the  products  of  conception 
are  completely  or  partially  taken  away,  ^\dth  or  "without  the  sac 
which  contains  them. 

Leading  obstetricians  are  not  agreed  as  to  the  treatment  of 
this  affection,  but,  as  a  whole,  they  remain  averse  to  active 
operative  measures  until  septic  symptoms  have  developed. 
They  still  advocate  injections  of  morphine  or  other  agents  into 
the  sac,  puncture  of  the  sac  and  removal  of  liquor  amnii,  and 
destruction  of  the  o^Tim  by  electricity.  The  surgical  operations 
which  I  shall  describe,  after  a  brief  sketch  of  the  diagnosis  and 
varieties  of  extra-uterine  gestation,  are — incision  of  the  sac 
through  the  vagina,  and  delivery  of  the  foetus ;  extirpation  of 
the  sac  by  abdominal  section  at  the  time  of  rupture ;  removal  of 
the  foetus  thi-ough  incision  of  the  sac  uni'uptured  or  at  the  time 
of  rupture  ;  extirpation  of  the  unruptured  sac  before  term,  and 
extirpation  of  the  sac  after  term.  The  less  radical  measures, 
just  named,  ■uill,  however,  be  briefly  noticed. 

Diagnosis  and  Varieties  of  Extra-uterine  Preg- 
nancy.— I  am  compelled  to  dismiss  these  two  important 
subjects  in  a  few  short  paragraphs.     The  excellent  s\mimary 


VARIETIES    OF    EXTKA-UTERINE    PREGNA^XY. 


351 


publislied  by  Freuncl  a  few  years  since*  will  form  the  basis 
of  my  remarks. 

In  tbe  earlier  stages  of  pregnancy  the  position  of  the  tumour, 
distinct  from  the  uterus,  is  easily  detected.  Later  on  it  becomes 
more  and  more  difficult  to  distinguish.  On  the  other  hand,  the 
general  symptoms  of  pregnancy  are  at  first  absent,  and  later 
they  are  more  likely  to  be  present.  This  is  an  excellent  rule, 
but  every  individual  case  will  present  more  or  less  puzzling- 
features.  Careful  examination  of  the  pelvic  viscera  and  the 
tumour  should  be  made  under  chloroform,  without  the  use  of 
the   sound.      The   nature   of   all    recent   discharges   must    be 


Fig.  133. — Gestation  in  Outer  Portion  of  Left  Fallopian  Tube. 
Death   after   three   attacks   of  hemorrhage.       {Museum   R.C.S.,  Xo.  4,696.) 


inquired  into,  with  the  view  of  ascertaining  if  any  decidua 
has  been  expelled  from  the  uterus.  Diarrhoea  and  colicky 
pains  may  indicate  the  attachment  of  placenta  to  the  serous 
coat  of  the  intestine. 

Tubal  Gestation. — This  condition  is  recognized  by  inter- 
mittent pains  resembling  dysmenorrhcea  and  coming  on  early 
in  pregnancy,  and  by  sudden  attacks  of  peritonitis  ^vith 
symptoms  of  internal  haemorrhage.      It  is  certain  that  these 

*  See  translation  of  Freund's  "Extra-uterine  G-estation,"  by  Dr.  David  Smart, 
in  the  Edinburgh  Medical  Journal,  September,  November,  and  December,  1883. 


352       OPERATIVE    TREATMENT    OF    EXTRA-UTERINE    PREGXANCY. 

attacks  end  fatally  in  a  large  number  of  cases,  as  in  that 
whence  the  specimen  represented  in  Fig.  133  was  taken ; 
and  perhaps  Freimd  is  too  confident  that  in  a  considerable 
proportion  of  eases  the  peritonitic  symptoms  subside  entirely 
within  the  first  three  months.*  The  tubal  cyst  remains 
flattened,  and  alwaj^s  tends  to  ruptiu'e  early.  According  to 
Tait  and  others,  tubal  pregnancy  is  the  primary  condition  in 
all  other  forms  of  extra-uterine  gestation,  which  result  from 
ruptui'e  of  the  tubal  sac  and  partial  or  complete  transplanta- 
tion of  the  contents.  I  am  of  opinion  that  this  theory  is,  in  the 
main,  coiTect.  As  far  as  regards  operation,  it  is  of  little  im- 
portance, since  when  a  sac  is  incised  or  extirpated  its  connec- 
tions at  the  time  are  more  to  be  considered  than  its  origin. 

Ovarian  Gestation. — It  is  doubtful  whether  a  fa?tus 
can  develop  in  the  tissues  of  the  ovary,  or  whether  what  is 
termed  ovarian  gestation  signifies  pregnancy  in  the  outermost 
part  of  the  tube,  with  absorption  of  the  ovarian  tissues  or  with 
theii'  amalgamation  with  the  wall  of  the  sac.  I  am  in  favour 
of  the  latter  theory.  What  is  understood  by  the  term  "  ovarian 
gestation"  appears  to  begin  ^vithout  pain,  or  with  but  moderately 
painful  sensations.  The  tumour-  grows  rapidlj',  like  an  ovarian 
cyst ;  it  is  distinct  from  the  uterus.  Pregnancy  may  go  on  till 
full  time  ;  then  the  foetus  dies,  and  may  desiccate  or  may  putrefy. 

Abdominal  Gestation. — In  this  form  an  abdominal 
tumour  is  developed,  and  the  uterus  is  hard  to  define  owing  to 
displacement  and  more  or  less  adhesion  to  the  sac.  Pain  is 
often  absent,  and  gestation  generally  continues  to  term ;  then, 
after  indications  of  labour,  and  death  of  the  foetus,  characteristic 
changes  follow,  T^dth  final  spontaneous  elimination  of  the  foetus 
thi'ough  different  channels.  In  cases  of  abdominal  pregnancy 
with  insertion  of  the  placenta  on  the  serous  coat  of  a  coil  of 
intestine,  intestinal  catarrh  sets  in  dm-ing  the  first  few  months, 
and,  when  the  fo3tus  dies,  the  sac  decomposes  and  the  whole 
system  is  affected. 

Of  some  less  frequent  varieties,  such  as  tubo-uterine  or  tubo- 
ovarian  gestation,  I  shall  speak  in  the  com'se  of  the  description  of 
operative  proceedings.      I  must  further  remind  the  reader  that 

*  He  admits  that  care  must  be  taken  to  avoid  )iiistakiiig  a  htematoeele  for  an 
abortive  gestation. 


PALLIATIVE    AND    ACTIVE    TREATMENT.  353 

pregnancy  in  a  monstrous  or  malformed  uterus  may  simulate 
or  may  practically  be  identical  with  extra-uterine  pregnancy. 

Palliative  Treatment. — Rest  is  always  imperative  in  cases 
of  extra-uterine  pregnancy,  and  further  directions  for  the  manage- 
ment of  patients  subject  to  this  affection  will  be  found  in  works 
on  obstetrics. 

Active  Treatment. — Obstetricians  are  generally  agreed  in 
recommending  for  the  earlier  stages  of  extra-uterine  pregnancy 
electricity,  puncture  of  the  sac,  or  injection  of  chemical  solutions, 
to  kill  the  foetus,  or  else  removal  of  the  foetus  through  a  vaginal 
incision.  The  jiroper  treatment  of  advanced  pregnancy  of  this 
kind  is  much  disputed,  some  recommending  that  the  patient 
should  be  left  alone  until  the  foetus  is  dead,  and  that  when  its 
death  occm-s  no  operation  should  be  performed  unless  septic  or 
other  dangerous  symptoms  appear.  Others  are  in  favour  of 
"  the  primary  operation,"  which  signifies  the  removal  of  the 
living  foetus  by  abdominal  section,  generally  with  the  view-  of 
saving  mother  and  child. 

In  cases  of  extra-uterine  pregnancy  where  the  foetus  has  died 
and  the  nine  months  have  passed,  most  authorities  are  in  favour 
of  leaving  the  sac  alone  so  that  it  may  shrivel  up,  unless  bad 
symptoms,  already  noted,  set  in  ;  then  laparotomy  is  considered 
justifiable. 

Certain  surgeons,  however,  advocate  abdominal  section  as 
soon  as  the  abnormal  pregnancy  is  diagnosed,  and  fui'ther 
recommend  immediate  operation  when  symptoms  of  ruptui-e 
of  the  sac  appear.  The  more  complete  operations  have  already 
been  named  and  will  be  described. 

Piuidure  of  the  sac  is  generally  effected  by  means  of  a  Cock's 
trocar  or  some  similar  instrument,  which  is  thrust  into  the  sac 
through  the  rectal  or  vaginal  wall.  It  has  often  proved  fatal,  as 
in  a  case  which  will  presently  be  mentioned,  and  may  fail  to 
destroy  the  foetus. 

Injections  of  Chemical  Solutions. — One-fifth  of  a  grain  of 
morphine  has  been  injected  into  the  sac  by  means  of  a  hypo- 
dermic syringe  with  a  long  nozzle  in  at  least  foui*  cases,  vith 
the  result  of  arresting  the  pregnancy.  A  single  injection  has 
proved  sufficient  to  destroy  a  five  months'  foetus  ;  in  another 
case  the  injection  was  repeated  every  other   day  till  the  sac 

A    A 


354      OPERATIVE    TREATMENT    OF    EXTRA-UTERINE    PREGNANCY. 

began  to  diminish  in  size.     The  nozzle  of  the  s}Tinge  may  be 
passed  either  through  the  vaginal  or  abdominal  wall. 

Electricity. — The  ovum  has  been  destroyed  by  the  Faradaic 
and  galvanic  currents  in  many  cases  which  have  occui'red  in 
the  practice  of  distinguished  specialists.  The  Faradaic  current 
appears  to  be  preferable. 

In  records  of  successful  results  following  the  above  pro- 
cedures the  possibility  of  errors  in  diagnosis  must  ever  be 
taken  into  account. 

I  shall  now  proceed  to  describe  the  more  radical  operations 
already  noted. 

Removal  of  Foetus  by  Vaginal  Section. — As  some 
part  of  the  foetus  generally  presses  down  into  Douglas's  pouch, 
it  is  natural  that  incision  into  the  vagina  and  extraction  of  the 
foetus  through  the  wound  should  not  only  have  been  suggested, 
but  also  practised  with  good  results.  When  the  foetus  is  large 
this  method  is  hardly  permissible,  for  then  the  operator  may 
meet  with  some  of  the  ordinary,  and  with  other  and  extra- 
ordinary, obstacles  to  delivery  through  the  vagina.  The  foetal 
sac  often  presents  more  in  the  direction  of  the  abdominal  walls 
than  towards  the  vagina.  In  most  cases  a  vaginal  operation 
appears  unsurgical  in  comparison  with  an  abdominal  section ; 
the  former  is  done  in  the  dark,  and  drainage  is  not  so  easily  nor 
so  safely  maintained  as  when  it  is  adopted  after  abdominal 
section. 

There  are,  however,  cases  where  the  removal  of  the  foetus 
through  a  wound  in  the  vagina  appears  justifiable.  When 
the  evidences  of  extra-uterine  pregnancy  are  strong,  when 
the  foetus  is  still  small,  when  the  sac  does  not  rise  above 
the  hypogastrium  so  as  to  press  against  the  abdominal  walls, 
and  when,  on  the  other  hand,  the  foetal  head  appears  to  lie  well 
down  in  Douglas's  pouch,  then,  if  the  surgeon  should  judge 
that  an  immediate  operation  is  necessary,  the  method  now  under 
consideration  may  be  the  best.  The  operator  may  be  far  more 
used  to  deliver  a  foetus  than  to  open  the  abdominal  cavity. 
This  fact  must  not  be  forgotten. 

The  woodcut  (Fig.  134),  represents  a  case  of  tubal  pregnancy 
where  this  method  might  have  been  practicable.  A  foetus  of 
about  the  third  month  occupied  the  outer  part  of  the  right  tube. 


REMOV^AL    OF    FCETUS    BY    VAGINAL    SECTION.  355 

The  ovary,  as  I  found  on  careful  dissection,  liad  become  atro- 
phied, and  was  completely  concealed  between  the  festal  sac  and 
the  uterus.  The  patient  was  a  woman  aged  twenty-two,  there 
were  signs  of  pregnancy  ;  a  tumour  could  be  detected  deep  in  the 
hypogastrium,  and  it  projected  into  Douglas's  pouch.     Large 


Fig.  134.  —Uterus  and  Appendages. 

Showing  a  sac  in  the  outer  part  of  the  right  Fallopian  tube  containiug  a  fcetus. 
The  lower  part  of  the  sac  lies  in  the  direction  of  Douglas's  pouch.  The  left  tube 
is  obstructed  and  dilated.     {Muscwn  R.C.S.,  No.  4,694.) 

pulsating  vessels  could  be  felt  on  the  surface  of  the  tumoiu-. 
The  sac  was  in  this  case  tapped  with  an  aspirator  through  the 
rectum,  as  it  was  very  tense  and  threatened  to  bui'st.  A  pint 
of  bloody  fluid  was  removed,  and  a  little  iodine  solution  was 
injected  by  the  aspirator  and  removed  again.     Subsequently,  as 


356       OPERATIVE    TREATMENT    OF    EXTRA-UTERIXE    PREGNANCY. 

the  bleeding  persisted,  a  solution  of  equal  parts  of  liquor  feni 
perchloridi  and  water  was  injected,  and  this  checked  the  hsemor- 
rhage.  The  patient  passed  a  decidua  from  the  uterus  on  the 
third  day,  but  died  rather  suddenly  with,  symptoms  of  internal 
haemorrhage  on  the  fourth.  I  performed  a  necropsy  and  dis- 
covered that  the  j)eritoneum  was  full  of  blood.  This  had  issued 
from  an  aperture  in  the  back  part  of  the  sac,  which  formed  a 
tumour  about  six  inches  in  diameter.  This  tumour  lay  behind 
the  uterus,  extending  to  the  right  into  the  iliac  fossa,  displacing 
the  caecum,  and  also  backwards  as  far  as  the  fifth  lumbar 
A'ertebra.  It  did  not  approach  the  abdominal  Avails.  It  could  be 
seen  as  it  lay  to  be  a  dilatation  of  the  right  Fallopian  tube. 

The  aspiration  of  the  sac  was  done  after  due  deliberation, 
and  the  operator's  account  of  the  case  vnll  be  found  in  the 
twenty-fii'st  volume  of  the  Transactions  of  the  Obstetrical  Society  of 
London  (1879),  page  93,  in  a  monograph  supplemented  by  Dr. 
Eouth  AAdth  some  valuable  tables  of  reference. 

The  object  of  the  above  history  of  the  case  may  now  perhaps 
be  apparent  to  the  reader.  In  a  similar  case,  in  future,  some 
other  operation  might  appear  preferable  to  aspiration.  Ab- 
dominal section  would  have  been  extremely  difficult  in  this 
instance,  even  as  a  secondary  measure.  As  a  primary  step,  few 
surgeons  would  care  to  perform  it.  I  shall  presently  speak  of 
radical  operations  on  tubal  cysts  before  term.  The  upper  part 
of  the  sac  lay  far  from  the  abdominal  walls,  so  that  incision 
and  di'ainage  would  have  been  difiicult  to  effect.  Complete 
extii'pation  of  the  sac  would  have  been  impossible.  The  lower 
part  of  the  cyst  lay  well  down  in  Douglas's  pouch.  The  wood- 
cut (Fig.  134,  page  355)  explains  the  j)osition  of  the  cyst. 
Hence  it  was  well  placed  for  an  incision  through  the  vagina. 

The  Operation. — Paquelin's  thermo-cautery  is  very  efiicacious 
for  the  pm'pose  of  cutting  thi-ough  the  posterior  fornix  of  the 
vagina.  The  surgeon,  if  unskilled  in  its  use,  should  practise 
cutting  with  the  cautery-knife  through  organic  tissues  of 
different  density.  The  galvano-cautery,  with  the  strong 
platinum  knife  (Fig.  69),  is  in  some  respects  preferable  to 
tlie  thermo-cautery  (see  page  155). 

The  rectum  must  be  cleared  and  the  bladder  emptied.  The 
patient  is  laid  on  her  left  side,  after  the  anoesthetic  has  been 


VAGINAL    SECTION — OPERATION    AT   TIME    OF    "RUPTURE.  357 

administered,  or  on  her  back,  should  circumstances  make  that 
position  desirable.  The  vagina  must  be  washed  out  with  car- 
bolized  or  iodized  water,  and  then  thoroughly  explored.  A 
Sims'  speculum  should  be  passed  along  the  posterior  wall  close 
up  to  the  vaginal  roof,  and  when  the  thermo- cautery  is  used, 
the  rest  of  the  vagina  must  be  well  guarded  by  means  of  a  pad 
of  wet  lint  pressed  against  the  anterior  wall  by  a  flat  retractor. 
Then  the  cautery-knife  is  passed  up  to  the  roof  of  the  vagina 
behind  the  cervix,  and  an  incision,  curved.,  with  its  concavity 
forwards  and  about  an  inch  in  length,  is  cut  through  the 
vaginal  wall  into  the  cyst.  The  knife  must  be  kept  just 
sufficiently  hot  to  burn  well  and  to  check  haemorrhage ;  this  is, 
of  course,  effected  by  the  assistant  plying  the  bellows  of  the 
cautery  gently  and  slowly. 

The  placenta  may  be  cut  through,  but  the  risk  of  uncon- 
trollable hsemorrhage  when  this  occurs  is  not  so  serious  as 
was  once  supposed.  When  the  incision  has  been  made,  the 
operator  passes  his  forefinger  through  it  into  the  cavity  of 
the  sac,  and  after  ascertaining  the  position  of  the  foetus,  de- 
livers it,  leaving  the  placenta. 

The  cyst-cavity  must  be  washed  out  with  an  antiseptic  solu- 
tion and  carefully  drained  afterwards.  Some  authorities  re- 
commend that  it  should  be  packed  with  sahcylic  or  iodoform 
wool,  frequently  changed.  Otherwise,  a  curved  glass  drainage- 
tube  should  be  passed  into  the  cyst,  which  must  be  washed  out, 
very  gently,  through  the  tube  twice  a  day,  or  more  often 
should  there  be  signs  of  septic  infection.  The  placenta  will 
gradually  come  away,  and  the  wound  will  close  up. 

Operation  at  the  Time  of  Rupture. — Extirpation  of 
Sac. — Taking  for  granted  that  diagnosis,  symptoms,  the 
actual  condition  of  the  patient,  and  the  experience  of  the 
surgeon  justify  immediate  radical  operative  measui-es,  the 
following  paragraphs  will  show  the  steps  of  the  operation, 
as  described  by  its  chief  advocate,  Mr.  Lawson  Tait. 

I  must  first  repeat  a  declaration  of  a  general  principle  which 
particularly  applies  to  this  operation,  that  the  surgeon  must  not 
leave  himself  out  of  account  as  one  of  the  factors  of  the  whole 
proceeding.  He  is  most  assuredly  justified  in  refi-aining  fi'om 
operation,  •  should   he   feel   that   his   experience   in   abdominal 


358   OPERATIVE  TREATMENT  OF  EXTRA-I'TERINE  PREGNANCY. 

surgeiy  has  not  been  sufficient  to  inspire  him  with  the  con- 
fidence neeessaiy  in  an  encounter  with  the  gravest  complication 
of  one  of  the  deadliest  of  disorders.  He  must  remember  that 
clearing  clots  and  fluid  blood  out  of  the  peritoneal  cavity,  and 
seeking  the  soiu-ce  of  haemorrhage,  require  much  nerve,  and 
that  in  the  pelvis  things  are  not  as  they  seem,  or  rather,  as 
they  feel.  An  "  educated  finger  "  is  indispensable.  If,  on  the 
other  hand,  the  sui'geon  who  contemplates  an  operation  of  this 
kind  has  had  considerable  experience  in  abdominal  sections,  he 
is  justified  in  at  least  making  an  explorator}^  incision.  Then, 
the  abdominal  cavity  being  opened,  he  can  but  search  for  the 
appendages ;  he  is  well  qualified  to  do  such  work,  nor  will  blood 
or  clot  affright  him.  However  deep  in  the  pelvis  the  seat 
of  disease  may  lie,  he  is  accustomed  to  search  the  pelvic 
structui'es  by  the  sense  of  touch  as  well  as  b}'  sight,  and  there- 
fore he  is  competent  to  attempt,  not  only  the  arrest  of  haemor- 
rhage, but  the  deliberate  extirpation  of  the  fcetal  cyst.  Mr. 
Tait,  an  extreme  advocate  of  the  proceeding  under  consideration, 
writes:*  "For  this  treatment,  of  course  the  difiiculty  was  the 
diagnosis,  but  as  I  have  now  completely  adopted  the  principle 
of  always  opening  the  abdomen  when  I  find  a  patient  in 
danger  with  abdominal  sjmiptoms,  this  barrier  no  longer  exists. 
The  diagnosis  is,  however,  not  so  very  difficult  after  all,  for  in 
many  cases  the  existence  of  pregnancy  has  been  suspected  before 
the  ruptui'e  occurred.  It  may  be  in  the  majority,  however,  that 
this  misleading  feature  is  present ;  the  patient  has  never  been 
pregnant,  or  has  not  been  so  for  many  years,  and  then  the 
arrest  of  menstruation  attracts  no  particular  attention.  If, 
however,  it  be  found  that  the  patient  has  been  eight  weeks  or 
more  mthout  a  period,  that  there  is  a  pelvic  mass  fixing  the 
uterus  and  on  one  side  of  it,  and  that  sudden  and  severe  symp- 
toms of  pelvic  trouble  and  haemorrhage  came  on,  the  rupture  of  a 
tubal  pregnancy  may  be  at  once  suspected,  and  if  an  operation 
is  to  be  done — and  it  clearly  ought  to  be  done — it  must  be  done 
■without  delay.  Early  interference  is  clearly  a  chief  element  of 
success  in  modern  abdominal  surgery." 

Whilst  the  preparations  are  being  made  for  the  operation, 

*  "Five   Cases  of  Exti'a-uteiine   Pregnancy   operated  upon   at  tlie  Time  of 
Rupture"  [British  Medical  Journal,  vol.  i.,  1884,  p.  1,250.) 


EXTIRPATION    OF    THE    RUPTURED    SAC.  359 

the  patient's  abdominal  aorta  should  be  compressed,  if  possible. 
It  is  probably  best  to  select  chloroform  as  the  aneesthetic,  for 
the  patient  can  be  brought  very  speedily  under  its  influence. 
This  is  specially  advisable,  since  there  is  no  time  to  be  lost, 
and  struggling  may  increase  the  danger.  Sudden  contrac- 
tions of  the  recti  during  imperfect  insensibility  will  assuredly 
increase  the  surgeon's  difficulties  and  the  patient's  peril. 

The  patient's  body  had  better  be  jorotected  with  towels,  as 
directed  in  the  account  of  the  operation  of  oophorectomy. 
The  incision  is  made  in  the  usual  manner  in  abdominal 
sections,  and  should  not  exceed  three  inches  in  length.  It 
must  be  brought  down  sufficiently  low,  else  there  will  be 
great  difficulty  in  reaching  the  pelvic  organs.  The  sm-geon 
then  clears  out  as  much  clot  as  will  enable  him  to  get  at  the 
appendages,  for,  especially  if  the  symptoms  be  urgent,  it  is 
evident  that  the  arrest  of  haemorrhage  is  all-important,  whilst 
the  peritoneal  cavity  can  be  cleaned  at  leisure  later  on. 

The  surgeon's  left  hand  *  is  then  j)assed  down  till  the  fundus 
uteri  can  be  detected  ;  the  operator  will  then  know  his  bearings, 
and  can  feel  the  relations  of  the  uterus  to  the  tumour.  The 
exact  limits  of  the  tumour  may  be  very  hard  to  define.  As  in 
oophorectomy,  adhesions  may  be  manifold,  nor  is  it  always 
easy  to  distinguish  adherent  empty  intestine  by  touch.  The 
next  thing  to  ascertain  is  whether  the  cyst  be  small  and  of 
such  a  nature  as  to  be  readily  removed  with  the  tube,  or  large 
so  as  to  require  stitching  to  the  abdominal  wound.  The  broad 
ligament  between  the  uterus  and  the  sac  must,  if  possible,  be 
grasped  between  the  left  finger  and  thumb,  so  that  the  haemor- 
rhage may  be  controlled. 

If  the  sac  be  small,  as  in  Fig.  135,  it  must  be  removed 
Tvdth  the  tube.  G-entle  pressure  with  a  sponge  will  check  the 
bleeding ;  this  should  be  done  by  the  assistant.  The  affected 
appendage  is  then  drawn  up,  sac  and  ovary  included,  by  the 
surgeon's  right  hand,  and  removed  precisely  after  the  manner 
described  in  the  account  of  oophorectomy  at  page  280.  The 
large  pressure-forceps  is  made  to  secia-e  the  appendage,  and  the 
pedicle-needle  armed  with  No.  4  silk  is  passed  on  its  proximal 

*  That  is,  if  the  sac  lie  in  the  right  appendages.  For  operations  on  the  other 
side,  the  position  of  tlie  hands,  as  here  described,  should  be  reversed. 


360       OPERATIVE    TREATMENT    OF    EXTRA-I'TERINE    PREGxVANX'Y. 

side  as  in  Eig.  114,  page  2<S1.  It  is  evident  that  when  the 
tubal  cjst  is  small,  as  in  Figs.  133,  135,  there  maybe  relatively 
little  difficulty  in  removing  it,  together  with  the  ovary,  as 
though  the  two  formed  a  diseased  appendage.  On  the  other 
hand,  shoidd  the  pregnancy  prove  to  be  tubo-aterine  or  "inter- 
stitial," as  in  Fig.  136,  supra-vaginal  hysterectomy  (Chapter 
XI.)  would  be  necessary. 

The  management  of  adherent  intestine  and  omentum  (page 
278),  the  cleaning  of  the  peritoneum,  and  the  after-treatment 


Fig.  135. — Tubal  Pregxaxcy. 

A  bristle  is  seen  passing  from  the  inteiior  of  the  cavity  to  the  uterine  end  of 
the  tube.  The  fimbriated  extremity  has  been  split  open  for  some  distance,  and  a 
bristle  passed  into  the  tubal  canal ;  this  bristle  could  not  be  passed  into  the 
cavity.  The  embryo  has  been  lost.  From  a  -woman  aged  thirty-three,  who 
died  suddenly,  Avitli  signs  of  internal  hemorrhage.  Dr.  Walter  Lowe,  of 
Burton-on-Trent,  discovered  the  cause  of  htemorrhage  when  making  a  necropsy 
of  the  case.      {Museum  R.C.S.,  No.  4,695.) 

will  be  the  same  as  in  ovariotomy.  It  is  advisable  to  exercise 
some  caution  in  pulling  out  clots  with  the  hand,  as  they  are 
not  firm,  so  that  if  a  large  clot  be  pulled  out  of  some  deep  part 
of  the  pelvis  or  abdomen,  a  portion  may  be  left  behind,  escaping 
the  notice  of  the  operator.  No  method  of  clearing  the  peritoneal 
cavitj'',  in  the  course  of  this  operation,  is  superior  to  thorough 
washing  out  with  several  pints  of  water  at  blood  heat.  I  have 
spoken  of  this  practice  in*  the  chapters  on  Ovariotomy,  where  I 
have  noted  the  necessary  precautions  (page  204) .      In  respect 


EXTIRPATION    AND    INCISION    OF    RUPTURED    SAC.  361 

to  extirpation  of  the  extra-uterine  sac,  as  in  all  other  ahclominal 
sections,  I  have  left  the  antiseptic  question  open.  Here  as  else- 
where I  should  prefer  to  employ  the  spray.  I  mention  this  matter 
in  relation  to  the  subject  of  washing  out  the  peritoneum  because, 
consistently  with  antiseptic  principles,  the  water  should  be  car- 
bolized,  in  the  usual  proportion  of  1  in  40,  or  about  2  per  cent, 
of  phenol. 

Lastly,  the  pelvic  viscera  must  be  carefully  examined  before 
the  wound  is  closed.     There  may  be  very  considerable  capillary 


Fig.  136. — Tubo-Utebine  ok  "Interstitial"  Pkegxancy. 


The  posterior  wall  of  the  uterus  has  been  partly  removed.  A  black  bristle 
passes  from  the  uterus,  across  the  cavity  which  contained  the  foetus,  into  the 
tube  beyond  it,  emerging  from  an  incision  artificially  made  through  the  tube. 
(Dr.  Carr  Roberts'  case,  Museum  R.C.S.,  No.  4,691.) 

oozing  from  the  side  of  old  adhesions  to  the  sac.  In  such  a  case, 
it  will  be  best  to  insert  a  glass  drainage-tube  into  Douglas's  pouch, 
and  drain  in  the  manner  already  narrated.  The  abdominal 
wound  is,  lastly,  closed  and  the  patient  is  returned  to  bed,  and 
treated  as  an  ovariotomy  case. 

Operation  at  Time  of  Rupture — Simple  Incision  of 
Sac. — I  have  just  described  the  operation  of  extirpation  of  the 
sac  at  the  time  when  symptoms  of  rupture  have  appeared  and 


362   OPERATIVE  TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 

the  sac  is  found  to  be  small.  It  may  happen,  however,  that  the 
pregnancy  is  advanced  to  the  third  or  f  om^th  month,  if  not  later, 
then  the  sac  will  he  of  considerable  size  and  its  extirpation 
would  be  difficult  and  dangerous.  The  proper  radical  course 
will  then  be  incision  of  the  sac,  and  removal  of  the  foetus,  the 
edges  of  the  sac  being  afterwards  sewn  to  the  abdominal  wound. 
The  rent  may  be  wide  enough  to  allow  of  the  extraction  of  the 
foetus,  and  if  not,  the  incision  must  be  made  to  include  it. 
Shoidd  the  rent  unfortunately  he  deep,  in  the  posterior  part  of 
the  sac,  this  arrangement  will  not  be  possible.  The  bleeding 
edges  of  the  rent  should,  in  this  case,  be  secured  by  means  of 
pressure-forceps,  the  handles  of  which  can  be  left  dependent 
from  the  abdominal  wound,  and  they  can  be  removed  in  about 
twenty-four  hours,  the  surgeon  carefully  watching  for  hsemor- 
rhage  after  the  forceps  are  taken  off.  Any  attempt  at  total 
extirpation  of  the  sac  is  unadvisable.  It  is  true  that,  after  tenn, 
under  different  conditions  to  those  existing  after  rupture,  that 
proceeding  may  bo  justifiable,  as  will  shortly  be  explained, 
yet  it  might  then  prove  very  difficult  on  account  of  complicated 
adhesions.  In  the  present  case,  however,  though  there  may  be 
few  adhesions,  the  sac  mil  be  soft,  succulent,  and  highly  vascidar, 
being  full  of  vessels  in  active  service,  so  to  speak.  The  risk  of 
rashly  detaching  such  a  sac  from  its  deep  connections  will  be 
evident ;  the  htemorrhage  would  certainly  be  severe  and  quite 
sufficient  to  startle  even  a  bold  operator. 

The  steps  of  the  operation  will  otherwise  be  identical,  in  this 
case,  with  those  of  the  same  operation  performed  when  there- 
has  been  no  ruptm^e,  or  after  term,  as  T^dll  now  be  described. 

Removal  of  an  Extra-uterine  Foetus  by  Incision 
through  the  Unruptured  Sac. — This  operation  may  become 
necessary  when  there  is  strong  evidence  that  a  foetus  which  has 
died  before  or  after  term  is  decomposing  and  setting  up  com- 
plications of  a  serious  character.  Should  abnormal  pregnancy 
and  retention  of  a  foetus  be  diagnosed,  should  the  sac  present 
well  towards  the  abdominal  walls,  and  should  the  patient  lose 
flesh,  suffer  from  chronic  or  sub-acute  peritonitis  or  exhibit 
symptoms  of  septic  infection,  this  operation  will  be  thoroughly 
justifiable.  There  may  be  evidence,  too,  that  some  communi- 
cation between  the  sac  and  the  rectum,  vagina,  or  other  organ. 


INCISION    THROUGH    THE    UNRUPTURED    SAC.  363 

is  in  process  of  formation,  threatening  fistulous  tracks,  and 
discharge  of  the  foetus  and  placenta  piecemeal,  to  the  certain 
discomfort,  at  least,  of  the  unfortunate  patient.  Some  surgeons 
believe  that  all  the  above  complications  should  be  anticipated, 
and  that  in  any  case  of  extra-uterine  pregnancy  prolonged 
beyond  term,  the  foetus  should  be  removed  in  case  such  evil 
results  should  follow  and  render  the  patient  less  fit  for  a  serious 
operation. 

The  patient  should  be  prepared  as  for  ovariotomy,  and  the 
abdominal  incision  made  about  four  inches  long.  Grreat  care 
must  be  exercised  when  the  surface  of  the  sac  is  exposed.  It 
is  here  taken  for  granted  that  the  diagnosis  is  correct.  Feehng 
assured  on  this  point,  the  operator  must  ascertain  the  relations 
of  the  front  of  the  sac.  If  it  be  adherent  to  the  parietes  he 
must  not  disturb  its  connections,  but  must  at  once  lay  it  open. 
If  not  adherent  superficially,  the  right  hand  should  be  passed 
over  the  surface  of  the  sac  to  ascertain  its  attachments.  During 
this  manoeuvre  any  deep  adhesions  which  may  exist  will  be 
detected.  Such  adhesions  must  be  on  no  account  distm-bed,  and 
the  operator  must  not  be  over-anxious  to  trace  the  precise 
anatomical  relations  of  the  sac  to  the  uterus  and  other  organs 
at  the  cost  of  tearing  down  adhesions,  setting  up  haemorrhage^ 
or  bursting  the  sac  itself  posteriorly.  A  sac  of  this  kind  should 
be  stitched  to  the  margin  of  the  abdominal  wound,  an 
elliptical  portion  being  first  cut  out  of  its  wall,  so  as  to  leave  a 
hole,  wide  enough  for  the  extraction  of  the  foetus.  The  sutures 
must  be  applied  separately  to  each  side  of  the  abdominal 
incision  and  the  corresponding  border  of  the  incision  in  the 
sac,  and  not  passed  through  both  sides  of  the  same,  crossing 
the  cavity  of  the  sac.  If  the  sac  be  not  made  fast  in  the 
manner  just  described  (as  in  Fig.  107),  some  of  its  contents 
will  escape  into  the  peritoneal  cavity  as  the  foetus  is  being 
extracted,  an  accident  to  be  avoided  thi'oughout  and  after 
the  operation.  For  the  stitching  process,  a  stout  curved 
suture-needle,  armed  with  No.  4  silk  or  with  thick  silkworm- 
gut,  will  be  found  convenient,  and  it  should  be  entered,  if 
possible,  through  the  healthy  tissues  of  the  abdominal  wound, 
and  cleaned  in  carbolic  solution  after  it  has  traversed  the 
diseased  wall  of  the  sac. 


364       OPERATIVE    TREATME>'T    OF    EXTKA-ITERINE    PREGNAXCY. 

Wlien  the  sac  is  adlierent,  a  simple  incision  may  be  sufficient; 
still  it  is  usually  advisable  to  secure  its  edges  to  the  abdominal 
wound,  lest  the  adhesions  be  broken  down  during  the  later 
stages  of  the  operation.  Should  the  placenta  be  cut  through, 
there  will  be  little  fear  of  htemorrhage,  as  that  structure  is 
generally  degenerate  and  does  not  bleed  much. 

The  extraction  of  the  foetus  must  be  managed  with  great 
deliberation,  as  the  sac  may  otherwise  be  ruptured,  or  the 
placenta  detached.  The  foetus  should  be  seized  by  its  feet 
and  drawn  out  slowly,  the  umbilical  cord  being  divided.  If 
it  be  putrid  it  should  be  extracted  by  a  large  volsella  or  by 
hthotomy-forceps.  Then  the  cavity  of  the  sac  is  washed  out 
with  any  antiseptic  fluid  in  which  the  operator  specially  puts 
his  trust.  A  drainage-tube  is  passed  into  the  deepest  part  of 
the  sac  and  the  cavity  is  packed  with  iodoform  wool.  Some 
operators  dust  the  walls  of  the  cavity  with  a  dry  antiseptic 
powder.  An  india-rubber  cloth,  already  described  (page  128) 
should  be  fitted  over  the  mouth  of  the  tube.  Over  the  whole 
a  large  woollen  pad  and  a  many-tailed  bandage  are  adjusted. 

The  sac  must  be  well  washed  out  through  the  drainage-tube, 
t"v\ace  daily,  or  more  frequently  if  necessary,  until  the  antiseptic 
fluid  used  for  washing  retui-ns  clean,  and  the  cavity  of  the  sac  is 
free  from  f oetor.  When  bad  odours  and  much  discharge  continue 
for  several  weeks,  the  walls  of  the  cavity  should  be  well  explored, 
for  in  some  cases,  especially  when  a  putrid  foetus  has  been 
removed  in  pieces,  a  foetal  bone  may  be  left  embedded  in  the 
wall  of  the  sac,  and  until  it  is  cautiously  extracted,  these 
dangerous  symptoms  will  persist.*  The  placenta  will  gradually 
come  away.  After  each  washing,  the  cavity  must  be  packed 
with  iodoform  wool.  When  the  discharge  becomes  trifling  and 
the  sac  has  begun  to  dry  and  shrink,  the  tube  may  be  removed 
and  the  packing  discontinued.  Care  must  be  taken  lest  the 
abdominal  wound  close  too  soon. 

As  it  often  happens,  where  this  operation  is  necessary,  that 
the  patient  is  in  a  very  feeble  state  of  health,  her  strength 
must  be  well  supported.  Should  there  be  a  tendency  to  vomit, 
or  even  simple  nausea,  nutrient  beef-tea  enemata  must  be  given, 
for  by  persisting  in  the  administration  of  food  by  the  mouth, 

*  See  Spaiiton,  Britifih  Medical  Joxuaal,  vol.  i.,  1884,  p.  14. 


EXTIRPATION    OF    SAC    BEFORE    AND    AFTER   TERM.  365 

serious  gastric  disturbance  will  be  set  up,  and  even  a  very  slight 
complication  may  turn  tbe  scale  against  the  patient's  recovery. 
Scrupulous  attention  is  needed  to  avoid  the  formation  of  bed- 
sores.    Opium  should  be  used  as  sparingly  as  possible. 

Extirpation  of  the  Unruptured  Sac  before  Term. — 
In  the  com'se  of  an  exploratory  operation,  an  extra-uterine 
pregnancy  may  be  discovered.  If  the  sac  be  of  a  nature 
suitable  for  extraction — that  is,  if  it  bear  a  good  pedicle,  as  in 
Fig.  135,  and  be  free  from  strong  adhesions — it  may  be  removed, 
the  pedicle  being  ligatured  as  in  ovariotomy.  As  a  rule,  how- 
ever, the  operation  just  described  is  the  best  to  perform  under 
the  circumstances. 

Extirpation  of  the  Extra-uterine  Sac  after  Term. — 
This  is  an  operation  of  extreme  difficulty  and  danger.  Even 
an  experienced  ovariotomist  or  obstetrician  may  shun  it  on 
account  of  the  numerous  risks  which  it  involves.  It  may 
happen  that  in  the  course  of  an  exploratory  operation,  where 
extra-uterine  pregnancy  is  hardly  expected,  that  condition  may 
be  discovered  when  the  surgeon  has  already  separated  a  great 
part  of  the  sac  from  close  adhesions  which  supply  it  with  blood. 
He  may  then  fear  to  leave  the  sac  behind.  Still  more  will  he 
object  to  incomplete  measiu-es  should  the  diagnosis  be  revealed 
by  sudden  rupture  of  the  sac  during  manipulation,  and  escape 
of  the  foetus.  The  rupture  may  be  so  wide,  or  placed  in  such 
a  position,  as  to  prevent  the  operator  from  contenting  himself 
with  simple  extraction  of  the  foetus.  The  sac  and  placenta 
may  also  be  extensively  diseased,  rotten,  or  sloughy. 

Under  these  circumstances,  and  especially  where  the  tissues  of 
the  sac  are  as  great  sources  of  danger  to  the  patient  as  the  dead 
foetus  itself,  simple  extraction  of  the  foetus  may  be  insufficient. 
Extirpation  of  the  sac  would  then  be  justifiable. 

The  abdominal  incision  being  made,  it  will  first  be  necessarj^ 
to  explore  the  surface  of  the  sac.  Sometimes  it  is  quite 
thin,  and  the  foetus  can  be  felt  through  its  walls.  Often, 
however,  it  is  very  thick,  being  partly  made  up,  anteriorlj^, 
of  overgrown  placenta.  The  surface  is  generally  dull  brown, 
but  may  vary  to  an  indefinite  degree.  Omental  and  intestinal 
adhesions  usually  exist,  and  may  be  extremely  difficult  to 
separate.     In  one  case  in  my  own  and  one  in  a  distinguished 


366      OPERATIVE    TREATMENT    OF    EXTRA-UTERINE    PREGNANCY. 

colleague's  practice,  the  sac  looked  so  like  an  ovarian  cj^st, 
that  the  trocar  was  thrust  into  its  substance  ;  no  fluid  escaped, 
but  the  wound  in  the  wall  of  the  sac  presented  no  pathogno- 
monic appearances,  indeed  the  wounded  tissues  resembled  the 
substance  of  a  somewhat  firm  sarcoma,  nor  could  any  foetus  be 
felt  by  the  finger  thrust  into  the  wound.  As  in  simple  extrac- 
tion of  the  foetus,  the  operator  must  prove  the  nature  of  the 
tumour  by  a  small,  carefully-made  incision  into  its  anterior 
wall,  and  must  be  prepared  for  the  contingency  of  error  in 
diagnosis,  shown  by  profuse  haemorrhage  and  escape  of  soft 
sarcomatous  material.  On  the  other  hand,  he  may  have  erred 
in  the  opposite  direction,  and  may  not  find  out  his  mistake  until 
he  sees  a  foetus  escape  through  a  rent  in  what  he  took  for  a 
uterine  or  ovarian  tumour. 

It  is  advisable  to  remove  the  foetus  from  the  cavity  of  the  sac 
and  to  divide  the  umbilical  cord  at  this  stage.  The  sac  must 
then  be  raised,  and  all  adhesions  at  its  upper  and  back  part  very 
carefully  and  deliberately  separated.  In  the  meantime,  the 
abdominal  incision  may  have  required  extension  upwards,  even 
above  the  umbilicus.  The  intestines  must  be  well  guarded  with 
flat  sponges.  When  the  base  of  the  cyst  appears  to  be  within 
range  of  the  operator's  hand,  he  must  thoroughly  explore  the 
pelvic  viscera  with  one  hand,  holding  up  the  cyst  with  the 
other.  Most  probably  he  will  find  the  fundus  of  the  uterus, 
but  he  must  not  be  surprised  if  he  fail  to  find  either  or  both 
ovaries  or  tubes,  nor  must  he  be  too  ready  to  diagnose  the 
precise  character  of  the  pregnancy  on  the  strength  of  manual 
examination  alone.  In  more  than  one  case  of  this  operation 
even  the  uterus  could  not  be  found. 

When  the  uterus  is  detected,  its  relation  to  the  sac  being 
verified,  the  surgeon  should  endeavour  to  form  a  pedicle,  and 
transfix  it  with  No.  3  or  No.  4  silk  as  in  ovariotomy.  This 
manoeuvre  has  proved  comparatively  easy.  Sometimes  the  base 
of  the  tumour  has  to  be  enucleated  from  the  broad  ligament, 
and  the  ragged  remains  of  the  ligament  will  afterwards  require 
trimming  and  transfixing.  Unfortunately,  the  connections  of 
the  base  of  the  cyst  with  the  deeper  pelvic  structures  may 
prove  very  intimate  and  impossible  to  separate  with  safety. 
In  such  a  case,  the  greater  part  of  the  sac  must  be  cut  away, 


EXTIRPATION    OF    THE    SAC    AFTER   TERM.  367 

and  the  edges  of  the  remaining  portion  sev/n  to  the  edges  of 
the  lower  part  of  the  abdominal  wound  with  silkworm-gut 
sutures.  A  glass  drainage-tube  is  then  passed  into  the  cavity 
of  the  remains  of  the  sac.  Before  this  is  done,  it  is  best  to  peel 
off  any  placenta.  If  adhesions  have  been  extensively  broken 
down  in  the  pelvis  towards  Douglas's  pouch,  another  drainage- 
tube  should  be  passed  into  the  pouch,  issuing  from  the 
abdominal  wound  above  the  point  where  the  sac  is  sewn  to 
its  edges. 

In  the  course  of  these  proceedings  the  pressure-forceps  will 
probably  be  required  freely.  The  heemorrhage  will  arise  chiefly 
from  broken-down  adhesions  and  from  their  proximal  side,  for 
there  will  be  little  bleeding  from  the  surface  of  the  sac.  Nor 
must  the  surgeon  expect  profuse  haemorrhage  from  its  interior. 
It  is  not  the  placenta,  nor  the  sac  wall,  which  will  give  him  most 
anxiety  in  this  respect.  The  chief  difficulty  in  regard  to  the 
placenta  may  be  its  identification.  In  one  operation,  where  I 
was  present,  it  was  so  much  altered  that  "  the  notion  that  it  was 
placenta  was  contested,  even  after  it  had  been  removed  from  the 
body  and  cut  completely  across,  by  some  of  the  most  eminent 
members  of  the  (Obstetrical)  Society."*  This  change  of  the 
placenta  into  a  thick  solid  mass,  resembling  the  substance  of 
some  forms  of  uterine  fibroid,  is  not  by  any  means  invariable 
after  term.  I  have  found  a  large,  very  characteristic  battle- 
dore placenta  in  an  extra-uterine  sac. 

The  intestinal  adhesions  are  sometimes  extremely  firm,  so 
that,  notwithstanding  ordinary  precautions,  the  walls  of  the 
adherent  gut  are  lacerated  and  require  very  careful  suture.  It 
need  hardly  be  said  that  important  structm'es  are  liable  to  be 
injured  during  the  separation  of  deep  pelvic  adhesions,  especi- 
ally the  ureters  and  large  vessels. 

In  some  cases  the  base  of  the  sac  is  most  readily  secm-ed  by  the 
wire  of  a  Koeberle's  serre-noeud ;  this  is  best  when  its  tissues  are 
very  thick  and  liable  to  bleed,  on  account  of  vessels  entering  its 
walls  through  pelvic  adhesions.  Should  the  operator  have  the 
misfortune  to  wound  the  uterus,  he  may  be  compelled  to  ampu- 
tate it  above  the  cer^dx,  using  a  serre-noeud  to  secure  the  stumj). 
It  is  impossible,  however,  to  make  allowance  for  every  contin- 

*  Thornton,  Trans.  Obslet.  Soc,  vol.  xxiv.,  1882,  p.  84. 


368   OPERATIVE  TREATMEXT  OF  EXTRA-UTERINE  PREGNANCY. 

gency  wliieh  may  arise  in  the  course  of  an  operation  of  this 
kind.  The  operator  must  quietly  proceed,  meeting  and  over- 
coming each  difficulty  as  it  is  encountered,  and  must  not  cease 
till  he  has  managed  to  secui'e  the  base  of  the  sac  after  one  of 
the  methods  just  described. 

The  after-treatment  must  be  conducted  on  the  same  principles 
as  when  a  large  ovarian  or  uterine  tumour  has  been  removed. 
There  is  usually  much  constitutional  debility  in  these  cases, 
hence  the  strength  must  be  kept  up  and  great  caution  exercised 
for  the  prevention  of  bedsores.  When  a  pedicle  has  existed 
and  has  been  ligatured  and  returned  into  the  peritoneal  cavity, 
the  case  will  resemble  an  ovariotomy.  When  the  base  of  the 
sac  is  left  behind  and  drained,  the  cavity  must  be  washed  out 
regularly  about  every  foui^  hom's  till  the  fluid  comes  away  clear 
and  scentless.  Then  the  glass  tube  may  be  removed,  and  replaced 
for  a  time  by  a  piece  of  gutta-percha  tubing,  if  necessary,  as  when 
the  cavity  is  very  deep.  The  cavity  should  be  kept  dry,  dusted 
with  iodoform,  and  packed,  when  it  gets  shallow,  with  iodoform 
wool;  but  surgeons  are  likely  to  insist  on  their  own  ideas  of 
antiseptic  dressing,  and  many  will  prefer  other  materials.  As 
the  tissues  of  the  sac  do  not  generally  bear  the  least  physical  or 
chemical  violence,  the  surgeon  must  handle  the  parts  very  care- 
fully and  avoid  strong  applications  like  pure  liquor  iodi  or  solid 
persulphate  of  iron. 

Grreat  care  must  be  taken  that  the  most  superficial  part  of 
the  abdominal  wound  does  not  close  till  all  the  parts  behind 
it  appear  healthy,  else  abscesses,  sinuses,  or  worse  complications 
may  result. 

When  Koeberle's  serre-noeud  is  used,  its  adjustment  and 
removal  must  be  effected  after  the  manner  described  in  the 
chapter  on  >Supra-vaginal  Hysterectomy. 


369 


CHAPTEE  XIV. 

CiESAREAX   SECTION   AND   PORRO'S   OPERATION. 

Preliminary  Observations. — These  operations  lie  entii-ely 
within  the  province  of  obstetrics.  A  surgeon  more  skilled  in 
abdominal  sections  than  experienced  in  midwifery  is,  however, 
occasionally  called  upon  to  perform  them.  For  this  reason 
I  introduce  descriptions  of  these  procedures  into  this  manual. 
For  the  obstetrical  and  ethical  questions  in  connection  with 
the  subject,  especially  the  relative  merits  of  these  two  operations 
and  craniotomy,  and  the  conditions  under  which  either  should 
be  performed,  standard  works  on  obstetrics  must  be  consulted. 

Caesarean  Section. — Professor  Sanger  has  devised  a 
method  of  performing  this  operation,  which  has  proved  so 
satisfactory  during  the  past  five  years,  that  I  consider  it  justifi- 
able to  describe  this  method  alone  at  length.  Earlier  operators 
of  great  experience  never  met  with  the  good  results  which 
Sanger  and  Leopold  can  claim,  especially  in  respect  to  the 
high  proportion  of  cases  where  both  mother  and  child  were 
saved.  The  life  of  the  mother  is  always  the  first  thing  to  be 
considered,  but  if  the  mortality  amongst  the  children  alone 
continued  high,  in  the  statistics  of  Ctesarean  section,  that  opera- 
tion would,  for  obvious  reasons,  still  remain  unsatisfactory. 

I  shall  not,  therefore,  describe  any  older  method,  but,  on  the 
other  hand,  I  shall  quote  Dr.  Sanger's  rules  for  the  simplifica- 
tion of  his  operation.  Had  he  invented,  so  to  speak,  a  surgical 
proceeding  only  practicable  in  a  large  hospital  or,  at  the  best 
only  to  be  undertaken  elsewhere  by  a  surgeon  experienced  in 
abdominal  section,  his  method  would  be  of  comparatively  Kttle 
value.     For,  often  when  it  is  necessary,  not  only  are  the  patho- 

B    B 


370  C-i:SAREAN    SECTIOX    AND    PORRo's    OPERATION. 

logical  conditions  unsatisfactory,  but  the  patient's  surroundings 
are  }'et  worse. 

On  that  account  I  sliall  first  describe  Sanger's  operation,  as 
it  should  be  performed  when  the  appliances  required  for  abdo- 
minal section  are  at  hand,  as  in  cases  where  the  patient  can  be 
removed  to  the  wards  of  a  hospital,  or  attended  by  experienced 
specialists  and  nurses.  I  shall  then  add  a  sketch  of  his 
simplified  method,  which  may  be  employed  in  an  emergency. 
For  more  complete  particulars,  Sanger's  "  Neue  Beitrage  zur 
Xaiserschnittsfrage  "  {An-Jiiv  fur  Gyniikologie,  vol.  xxvi.,  1885), 
and  a  more  recent  paper  by  the  same,  "  Ueber  Yereinfachung  der 
Technik  des  Kaiserschnittes  "  {Centralhlait  far  Gynal-olorju',  No. 
28,  1886),  must  be  consulted. 

It  is  not  necessary  for  me  to  add  the  details  of  a  controversy 
as  to  the  precise  share  which  Professor  Sanger  can  legitimately 
claim  in  the  establishment  of  this  modification  of  the  older 
method  of  performing  Csesarean  section.  This  question  is 
discussed  by  Dr.  Grarrigues  in  a  paper  named  "  The  Improved 
Ceesarean  Section"  {American  Journal  of  Obstetrics,  vol.  xix., 
page  1,009). 

Sanger's  Csesarean  Section:  The  Operation. — The 
patient  should  be  prepared  as  for  ovariotomy.  The  waterproof 
sheet  will  not  be  needed.  I  have  abeady  spoken  about  the 
question  as  to  when  this  appliance  should  be  employed  or  dis- 
carded (page  87).  Towels  must  be  placed  so  as  to  guard  the 
surrounding  parts,  as  in  oophorectomy.  Sanger  recommends 
the  spray,  and  several  pints  of  phenol  solution,  as  well  as  a 
1  per  cent,  solution  of  corrosive  sublimate,  must  be  at  hand. 

The  pubes  must  be  well  shaved.  Two  large  flat  sponges,  at 
least,  will  be  required  ;  it  is  better  to  have  four  at  hand.  A  set 
of  smaller  sponges  must  be  prepared ;  ten  vnll  be  sufficient 
(indeed,  Sanger  only  uses  four).  The  other  instruments  and 
appliances  that  will  be  needed  are — a  scalpel ;  a  probe-pointed 
knife  ;  a  catheter  ;  two  volsella  ;  six  pressure-forcej^s  ;  a  pair  of 
straight-bladed  scissors,  and  a  pair  curved  on  the  flat ;  a  needle- 
holder  ;  suture-needles,  straight  and  curved ;  silver  wire  for 
sutures;  ligature  silk,  Nos.  1,  2,  3,  and  4  (and  silkworm-gut  if 
desired) ;  a  yard  of  gutta-percha  tubing,  with  a  lumen  of  about 
one-fifth  of  an  inch,  for  elastic  ligature  ;  a  bottle  of  iodoform ;  and, 


saisjger's  cesarean  section.  371 

lastly,  several  soft  napkins.  Tlie  dressings  will  be  the  same  as 
in  ovariotomy,  and  the  surgeon  will,  in  any  case,  employ  them 
according  to  his  fancies  and  preferences  in  the  conduct  of  that 
operation. 

The  patient  is  placed  under  the  influence  of  the  anaesthetic, 
and  the  bladder  is  emptied.  The  abdomen,  vulva,  vagina,  and 
cervix  are  thoroughly  washed  with  the  antiseptic  solution. 

The  abdominal  incision  should  be  made  about  four  and  a  half 
inches  long ;  it  must  of  course  be  longer  than  when  a  collapsible 
cyst  has  to  be  removed,  and  should  begin  higher  up  than,  and 
not  be  brought  down  so  low  as,  in  ovariotomy.  Indeed,  Sanger 
recommends  that  one-third  of  the  entire  length  of  the  incision 
should  he  above  the  navel.  Three  sutures,  of  raw  silk  or  silk- 
worm gut,  are  now  passed  through  the  upper  third  of  the 
wound  and  left  untied.  In  this  way  that  part  of  the  incision 
may  readily  be  closed  after  the  uterus  is  drawn  out  of  the 
abdomen,  later  on. 

The  operator  must,  before  opening  the  uterus,  ascertain  that 
it  lies  centrally,  and  not  rotated  to  the  right  or  left.  It  will 
generally  be  found  twisted  to  the  right,  so  that  its  left  side 
presents  ;  it  must  be  put  straight  in  any  case,  and  the  foetus  is 
manipulated  into  a  favourable  position  should  it  lie  transversel}", 
as  is  often  the  case. 

Should  it  be  evident  that  the  foetus  is  dead  and  decomposing, 
the  uterus  must  now  be  turned  out  of  the  abdominal  incision 
before  it  is  opened.  Otherwise,  that  organ  must  be  laid  open  as 
it  lies  in  the  abdomen. 

If  the  patient  has  been  several  hours  in  labom^  and  the  cervix 
is  extremely  expanded,  the  incision  may  require  to  be  made 
horizontally,  and  low  down  on  the  anterior  surface  of  the 
uterus.  As  a  rule,  however,  the  incision  should  be  made 
vertically,  and  must  exactly  agree  with  the  abdominal  wound 
in  length  and  position.  Grreat  care  must  be  taken  not  to 
bring  it  down  too  low,  else  the  circular  venous  sinus,  which 
lies  in  the  uterine  walls  at  the  level  of  the  os  internum,  will 
be  opened.  This  misadventure  is  said  to  be  the  most  frequent 
cause  of  fatal  haemorrhage  during  or  after  Csesarean  section. 

The  foetus  must  now  be  extracted — by  the  head,  if  pos- 
sible.    If  the  arms  be  brought  over  the  head,  they  will  save 


372  CJESAREAN    SECTION    AND    PORRO's    OPERATION. 

the  neck  from  constriction  during  its  passage  through  the 
uterine  incision.  The  conditions  of  delivery  are  different 
from  those  which  exist  when  the  child  is  born  through  the 
natural  channel. 

The  uterus  is  now  gently  di'awn  forwards  out  of  the 
abdominal  wound.  A  flat  sponge  is  passed  into  the  abdo- 
minal cavity  behind  the  uterus,  and  high  up  beyond  the 
upper  angle  of  the  wound,  as  in  ovariotomy  when  the  cyst 
is  drawn  out.  The  edges  of  the  upper  part  of  the  wound 
are  approximated  by  dragging  on  the  sutures,  which  are  then 
held  together  by  pressure-forceps  in  such  a  manner  that  the 
wound  is  practically  closed,  yet  can  be  opened  directly,  when 
necessary,  by  taking  off  the  forceps. 

The  body  of  the  uterus  is  then  protected  by  a  napkin 
soaked  in  the  phenol  solution.  The  lower  segment  and  the 
cervix  may  now  require  manual  compression. 

The  elastic  ligature  is  then  passed  round  the  neck  of  the 
uterus,  its  ends  are  crossed  in  front,  and  held  together  by 
means  of  a  pressm-e-forceps.  The  operator  next  awaits  the 
spontaneous  detachment  of  the  placenta,  or,  if  necessary, 
carefull}''  detaches  it,  and  removes  the  membranes.  With 
regard  to  wounds  of  the  placenta  made  during  the  passage 
of  the  knife  through  the  abdominal  wall,  they  do  not  give 
rise  to  serious  haemorrhage,  as  was  once  supposed.  The  chief 
source  of  loss  of  blood  has  already  been  noted.  The  operator 
now  ascertains  that  the  internal  os,  or  its  site,  is  viable. 
If  not,  he  must  make  it  so  by  clearing  away  placenta  and 
mucus ;  then  there  will  be  a  free  outlet  for  discharges  in  the 
uterine  cavity  to  escape  into  the  vagina. 

The  uterine  cavity  and  cervix  are  now  freely  dusted  with 
iodoform.  It  is  best  to  clean  the  cavity  first  with  carbolic 
or,  better  still,  sublimate  solution,  and  to  syringe  the  solution 
into  the  vagina  from  the  cavity. 

The  next  stage  of  the  operation  consists  in  the  application 
of  the  sutures  to  the  uterine  wound.  This  is  done  after 
several  methods,  all  based  u^Don  two  principles.  The  mus- 
cular coat  should  be  deeply  transfixed,  but  the  decidua  avoided. 
The  surfaces  of  the  serous  coat  on  each  side  of  the  incision 
should   be   made   to  lie   in   apposition.      In  this  manner  the 


SANGER  S    CESAREAN    SECTION. 


373 


deep  part  of  tlie  wound  is  well  held  together,  and  the  serous 
surfaces  will  rapidly  unite,  as  they  do  in  an  ovariotomy 
wound,  and  close  the  superficial  part.  Many  sutures  should 
be  used,  as  the  tendency  of  the  uterine  contractions  and 
relaxations  to  act  deleteriously  on  the  wound  is  thereby  most 
readily  counteracted. 

Of  the  different  ways  of  attaining  these  objects  I  shall 
describe  the  simplest,  which  I  find  has  been  related,  after 
Sanger  and  Leopold's  original  directions,  by  Dr.  Lusk.* 
Sanger,  in  the  paper  to  which  I  have  abeady  referred, 
mentions  several  far  more  complicated  methods,  but  they  are 
not  of  a  kind  which  would  be  readily  practicable  to  an 
operator,  however   experienced,  who  is  suddenly  called  upon 


Fig.  137. — Diagram  kepee.senting  the  Edges  of  the  Uterine  Wound  as 

PREPARED   FOR   THE    SUTURES    IN    SANGER's   MODIFIED    CyESAREAN    SECTION. 

The  black  line  represents  the  serous  coat,  the  wavy  line  the  decidua.     (See  text.) 

to  perform  Csesarean  section ;  moreover,  it  will  be  seen  pre- 
sently that  Sanger  himself  has  laid  out  a  scheme  for  the 
greatest  possible  simplification  of  the  operation  under  such 
circumstances. 

The  cut  surface  of  the  serous  coat  on  each  side  of  the  uterine 
wound  is  raised  with  forceps,  and  about  a  cpiarter  of  an  inch 
is  dissected  up,  together  with  a  thin  layer  of  the  muscular  wall. 
Towards  the  extremities  of  the  wound  only  half  as  much  of 
the  serous  coat  should  be  raised,  as  midway  between  them. 
When  this  dissection  is  completed  on  each  side,  a  wedge- 
shaped   piece   of    the    muscular    wall    (closely   shaded   in   the 

*  The  Science  and  Art  of  Michoifcry.     New  York.     1885. 


374 


a^ISAREAN    SECTIOX    AND    PORRo's    OPERATION 


diagram,  Fig.  137)  is  cut  away  on  each  side  of  the  wound, 
the  base  corresponding  to  the  level  of  reflection  of  the  serous 
coat  superficially,  whilst  the  apex  of  the  wedge  touches 
the  decidua.  Thus  two  muscular  surfaces,  readily  made  to 
he  in  apposition,  are  formed,  and  they  are  overlapped  by 
a  layer  of  the  serous  coat.  The  lower  sketch  in  Fig.  137 
represents  this  laj^^er  turned  do^vn  on  the  muscular  tissue. 

Eight  to  ten  silver  sutures  are  now  jDassed  into  the  mus- 
cular wall,  at  about  half  an  inch  from  the  margin  of  the 
wound,  and  made  to  run  deeply  thi'ough  the  wall,  just 
avoiding  the  decidua,  and  passing  across  to  the  wall  on  the 
opposite  side  (Fig.  138).     Then  a  large  number   of  fine  silk 


Fig.  138. — Diagkam   repeesenting  the  Sutures  applied  to  the  "Wound 
sketched  ix  the  preceding  figure. 

The  inner  and  more  superficial  suture  passes  twice  through  the  serous  coat  on 
each  side.     {Sec  text.) 

sutui'es  (No.  1,  as  recommended  for  ovariotomy)  are  passed 
through  the  serous  coat  (Fig.  138),  the  dissected  part  of 
which  must  be  turned  down  against  the  muscular  coat,  so 
that  the  needle  may  transfix  it  on  both  sides.  In  this 
manner,  when  the  wires  are  made  fast,  the  muscular  walls 
will  be  brought  firmly  together,  and  the  surfaces  of  the 
inverted  portions  of  the  serous  coat  will  lie  in  perfect  appo- 
sition, and  unite  rapidly. 

The  elastic  ligature  is  now  removed,  the  uterus  thoroughly 
washed  out  with  the  sublimate  solution,  the  sutm-es  made 
fast,  and  the  hne  of  sutui'e  dusted  with  iodoform.  Any 
bleeding  point  on  the  uterus  must  be  secured  by  a  fine  silk 
suture,  passed  under  it  by  the  aid  of  a  needle,  and  the  two 
ends  are  tied  over  it.  If  the  bleeding  be  very  severe,  then, 
as  was  recommended  when  speaking  of  a  wound  in  the  surface 


sanger'vS  simplified  method.  375 

of  a  uterine  fibroid  that  is  not  found  suitable  for  removal 
(page  207),  one  end  of  the  silk  may  be  passed  once  more 
under  the  vessel,  as  nearly  as  possible  along  the  same  track, 
and  brought  out  at  its  original  point  of  exit ;  then  the  ends 
are  tied  across,  and  the  vessel  will  be  tightly  gripped. 

The  uterus  is  now  replaced,  with  its  fundus  forwards,  and 
not  upwards  or  backwards,  so  that  the  intestine  should  not 
get  between  that  organ  and  the  abdominal  wound.  The 
wound  is  then  closed,  and  the  line  of  suture  dusted  with 
iodoform ;  the  abdomen  is  dressed  with  iodoform  gauze  and 
wool,  held  on  by  means  of  broad  strips  of  plaster. 

With  regard  to  the  dressings  and  antiseptics,  the  English 
surgeon  would  in  many  cases  prefer  other  materials  to  those 
above  mentioned,  but  I  have  throughout  adhered  to  the 
recommendations  of  Sanger.  From  my  own  experience  of 
iodoform  in  abdominal  sections,  I  believe  it  to  be  very  ser- 
viceable. 

The  after-treatment  should  be  as  simj)le  as  possible.  The 
vagina  ought  not  to  be  washed  out  as  long  as  the  pulse  and 
temperature  remain  normal,  and  there  is  no  evidence  of 
retention  of  lochia. 

Last  year  (1886),  at  a  meeting  of  a  medical  society  (Deutsche 
Gresellschaft  fiir  Grynakologie,  see  Centralblatt  fur  Gyndkologie, 
No.  28,  1886)  in  Munich,  Dr.  Sanger  gave  statistics  of  his 
modification  of  Csesarean  section.  The  total  number  of  opera- 
tions amounted  to  thirty.  In  these,  the  mother  recovered  in 
twenty-one  cases,  and  twenty-seven  children  were  thereby 
saved.  Leopold  was  the  most  successful  operator.  In  his 
eleven  cases,  ten  mothers  and  eleven  children  were  saved. 

Equally  interesting  are  Dr.  Sanger's'  simplifications  of  his 
operation  for  the  benefit  of  practitioners  in  emergencies.  As 
they  may  prove  very  useful,  I  quote  them  below  almost  hterally. 

Prejximtion. — No  special  instrument,  such  as  an  ordinary 
surgeon  is  not  likely  to  have  at  hand,  is  needed.  Abdomen, 
vulva,  vagina,  and  cervix  to  be  washed  with  sublimate  solution, 
the  instruments  with  carbolic  solution.  Sponges,  if  not  to  be 
had,  may  be  replaced  by  wool  carefully  washed  in  one  of  the 
above  solutions.  Two  persons  sufiioient  to  assist.  "In  an 
emergency,  the  ansesthetic  may  be  confided  to  a  layman." 


376  CESAREAN    SECTION    AND    PORRo's    OPERATION. 

Abdominal  Incision. — Pressure-forceps  and  the  early  introduc- 
tion of  sutares  in  the  upper  part  of  the  wound  not  indispens- 
able. Except  when  the  foetus  is  dead,  it  is  not  advisable  to  lift 
the  unopened  uterus  out  of  the  woimd,  as  the  latter  might  then 
need  to  be  enlarged,  and  there  would  be  fear  of  escape  of 
intestine. 

The  Uterine  Wound  should  be  made  vertically  in  the  median 
line,  avoiding  the  lower  segment  of  the  uterus.  A  horizontal 
incision  is  difficult  and  unsuited  for  the  conditions  under  which 
these  simplifications  are  especially  needed.  When  the  placenta 
lies  in  the  line  of  incision,  cut  quickly  through  it,  or  detach  it 
laterally.  Sanger  finds  that  these  manoeuvres  may  be  done 
without  difficulties  from  haemorrhage  or  during  the  application 
of  the  sutures.  The  foetus  is  most  readily  pulled  out  by  the 
feet.  In  some  positions  of  the  head  the  uterine  wound  may 
require  prolongation  upwards. 

Temporary  Extraction  of  the  Body  of  the  Uterus  from  the 
Abdominal  Wound. — A  napkin,  antisepticized,  to  be  spread 
over  the  intestines;  another  to  be  folded  over  the  uterus. 
In  place  of  the  elastic  ligature,  compression  of  the  lower  part 
of  the  uterus  with  the  hand,  or  rotation  of  the  uterus  on  its 
long  axis.  Manual  detachment  of  the  placenta.  The  patency 
of  the  OS  to  be  proved.  Disinfection  of  the  uterine  cavity 
(iodoform).  A  sponge  or  strips  of  antiseptic  gauze  to  be  laid 
in  the  cavity  till  the  deep  sutures  are  applied. 

Sutures. — For  the  sake  of  simplicity,  the  dissecting  up  and. 
bending  inwards  of  the  serous  coat,  and  resection  of  the 
muscular  wall  may  be  omitted  when  there  is  no  marked 
retraction  of  the  former  nor  great  bulging  of  the  latter,  nor 
much  gaping  of  the  entire  wound.  The  edges  of  the  wound 
may  be  pared  and  adjusted,  just  as  in  any  other  operation. 
The  principle  to  observe  is  to  pass  eight  to  ten  deep  silver 
sutures  through  the  serous  coat  and  muscular  walls,  avoiding  the 
decidua,  and  to  apply  sixteen  to  thirty-five  silk  sutures  to  the 
serous  coat  alone,  with  double  transfixion  of  that  coat  on  each 
side  of  the  incision,  so  as  to  ensure  the  coaptation  of  two  serous 
surfaces  when  these  sutures  are  tied.  Other  material,  fine  silk, 
antiseptic  or  silkworm-gut,  may  be  used  in  default  of  silver 
wire.     Carbolized  catgut  should  never  be  used  for  the  uterine 


Sanger's  simplified  method.  377 

sutures.  In  one  case,  as  I  was  informed  by  an  obstetrician 
who  was  present  at  the  necropsy,  fifteen  carbolized  sutures  were 
used.  All  came  loose  excepting  one  at  the  lower  angle  of  the 
wound,  which  gaped  freely.  Sanger  insists  on  wire  for  the 
deep  sutures.  English  operators  will  probably  differ  from  him 
in  this  respect. 

Irngation  of  the  Uterus  from  within  with  a  one-half  per 
cent,  sublimate  solution  ;  application  of  iodoform  to  the  line  of 
suture,  closure  of  the  sutures ;  replacement  of  the  uterus  in  the 
abdominal  cavity,  but  not  until  all  bleeding  from  the  line  of 
suture  or  from  the  tracks  of  the  sutui'es  has  been  checked  by 
passing  a  fine  silk  thread  under  any  bleeding  point.  No 
drainage  ;  washing  or  sponging  out  the  peritoneal  cavity  not 
always  necessary.  Abdominal  wound  to  be  closed  with  silk 
sutures.  Then  the  integuments  should  be  dusted  with  iodoform. 
The  abdominal  walls  are  gently  supported  with  thin  strips  of 
plaster. 

Bladders  containing  ice  to  be  placed  on  the  abdomen,  and 
frequent  subcutaneous  injections  of  ergotin  to  be  given.  The 
after-treatment  must  be  as  passive  as  possible. 

There  can  be  little  doubt  that,  with  sundry  modifications  in 
accordance  with  the  practice  of  surgeons  outside  the  frontiers  of 
the  Grerman  and  Austrian  empires,  Sanger's  method  of  per- 
forming Csesarean  section  will  be  widely  and  successfully 
practised  in  the  immediate  future. 

Caesarean  Section  for  Rupture  of  the  Uterus.— I 
shall  presently  speak  of  a  modification  of  Porro's  operation, 
performed  when  rupture  of  the  uterus  has  occurred,  and  will 
show  that  the  usual  situation  of  the  rupture  is  unfavourable  for 
the  application  of  the  serre-noeud.  Unfortunately,  the  usual 
situation  of  the  rupture  is  almost  equally  inconvenient  for  the 
performance  of  an  operation  which  may  be  considered  as  a 
variety  of  Caesarean  section. 

When  rupture  of  the  uterus  has  been  diagnosed,  it  may  be 
said,  in  the  words  of  Dr.  Routh,*  that  it  is  an  unnecessary 
piece  of  cruelty  and  malpraxis  to  attempt  to  extract  the  child 
through  the  vagina,  and  to  irritate  the  bowels  with  the  hand. 

*  Discussion  on  Drs.  Swayne  and  Cox's  "Cases  of  Ruptured  Uterus  "  [Trans- 
actions of  the  Obstetrical  Society  of  London,  vol.  xxviii.,  1886,  p.  227). 


378  CiESAREAN    SECTION    AND    PORRo's    OPERATION. 

That  practice  involves  the  risk  of  enlarging  the  rent  in  the 
uterus,  and  increases  haemorrhage  and  shock.  The  rule  should 
be  to  proceed  at  once  to  abdominal  section.  The  circumstances 
implied  in  this  aphorism  are  sufficient  to  show  that  it  is 
generally  the  obstetrician  who  is  called  upon  to  operate  for 
ruptiu^ed  uterus.  Still,  as  in  the  case  of  Ctesarean  section 
under  more  usual  cu-cumstances,  he  may  prefer  to  leave  that 
daty  to  some  surgeon  who  may  be  at  hand. 

In  any  case,  as  regards  the  decision  of  the  operator  in  favour 
of  Csesarean  section  or  a  modified  Porro's  operation,  it  will  be 
necessary  to  make  the  abdominal  incision  first.  Then,  suppos- 
ing that  the  rent  lies  near  the  fundus,  it  may  be  of  a  character 
suitable  for  treatment  by  dissecting  up  the  serous  coat,  paring 
the  muscular  walls,  and  introducing  the  sutures,  after  Sanger's 
method  (page  373),  the  placenta  being  first  extracted.  The 
freedom  of  the  os  from  any  obstruction  j^i'eventing  free  escape 
of  the  lochia  must  be  ensured.  Directly  the  foetus  is  removed, 
previous  to  further  manipulation  of  the  uterus,  the  fundus  of' 
that  organ  should  be  raised  out  of  the  abdominal  wound,  and  a 
large  flat  sponge  passed  behind  it.  An  elastic  ligature  or  the 
hand  of  an  assistant  T\dll  also  be  needed  directly  the  abdominal 
cavity  is  opened.  In  general  respects,  the  steps  of  this  opera- 
tion will  be  the  same  as  in  the  usual  kind  of  Csesarean  section. 

When  the  rent  is  unfortunately  in  its  most  frequent  position, 
namely,  along  the  lower  segment  of  the  uterus,  extending  upward 
towards  the  body,  or,  worse,  do^\Tiward  towards  the  vagina, 
the  difficulties  and  dangers  of  Ca3sarean  section  will  be  greatly 
increased.  The  rent  is  chiefly  horizontal  in  these  cases,  turning 
upwards  or  downwards,  almost  at  a  right  angle,  at  one  extremity. 

This  fact  may  be  remembered  in  connection  with  the  sugges- 
tion of  Kehrer,  that  in  an  ordinary  Caesarean  section  the  incision 
should  be  made  transversely  and  at  the  level  of  the  os  internmn. 
The  great  objection  to  this  position  of  the  incision  is  the  presence 
of  the  circular  venous  sinus  at  this  very  point  (page  371). 

In  the  case  of  rupture,  however,  the  operator  has  no  choice, 
or  rather,  he  has  not  to  select  the  site  of  an  incision  and  then 
make  it,  but  to  rej^air  a  ready-made  wound.  This  simple 
principle  must  not  be  overlooked.  The  steps  of  the  opera- 
tion, when  the  ruptm^e  is  transverse,  will  be  much  the  same  as  in 


RUPTURE  OF  THE  UTERUS PORRO's  OPERATION.     379 

ordinary  Csesarean  section,  excepting  that  the  foetus  will  probably 
be  more  or  less  entirely  outside  the  uterine  cavity.  Other 
necessary  modifications  have  just  been  suggested  in  relation  to 
operation  for  rupture  of  the  fundus.  The  transverse  ruptui'e 
will  require  very  careful  application  of  the  sutures  after  Sanger's 
method. 

I  will  conclude  with  Dr.  Lusk's  comments  on  gastrotomy  for 
rupture  of  the  uterus*: — "The  results  of  gastrotomies performed 
for  the  removal  of  the  child  after  its  escape  into  the  abdomen  are 
extremely  encom'aging,  Trash's  statistics!  showing  76  per  cent, 
of  recoveries,  those  of  Jolly  69  per  cent.,  and  the  United  States' 
statistics,  collected  with  indefatigable  zeal  by  Harris,  53^-|-  per 
cent.  In  the  autopsies  I  have  witnessed  upon  women  who  have 
died  from  rupture  after  delivery  by  the  natural  passages  it  has 
always  seemed  to  me  that  a  timely  gastrotomy,  performed 
before  peritonitis  had  set  in,  would  have  afforded  a  good  chance 
of  saving  a  patient's  life." 

It  must  be  remembered  that  in  most  of  the  cases  included  in 
these  statistics  the  wound  was  not  sewn  up  in  the  systematic 
manner  adopted  by  recent  Grerman  authorities.  Had  it  been 
always  so  treated,  not  to  speak  of  other  precautions  only  lately 
suggested,  the  mortahty  would  undoubtedly  have  been  much 
lower. 

Porro's  Operation* — By  this  term  I  signify,  according 
to  Dr.  Grodson's  definition,!  Csesarean  section  followed  by 
removal  of  the  uterus,  together  with  its  appendages  (including- 
the  ovaries),  leaving  only  the  cervical  portion  of  the  uterus. 
Hence,  the  surgeon  may  liken  it  to  supra- cervical  hysterectomy 
for  fibroid  tumour  of  the  uterus :  but  for  the  conditions  involved 


*  Loc.  cit.,  ID.  610. 

t  The  surgeon  interested  in  the  subject  of  ruptui'e  of  the  uterus  shouki  consult 
Dr.  Trask's  vahiable  "Statistical  Inquiry  into  the  Causes  of  Rupture  of  the 
Uterus"  {American  Journal  of  the  Medical  Sciences,  vol.  xv.,  new  series,  1848). 
He  noted  that  in  only  11  out  of  265  cases  of  rupture  during  parturition  was  the 
laceration  found  to  occur  at  the  fundus.  On  the  other  hand,  it  was  discovered 
at  the  fundus  in  7  out  of  38  cases  of  rupture  during  gestation.  Subsequent 
researches  have  confirnied  the  accuracy  of  these  statistics. 

+  "  Porro's  Operation  "  :  Introduction  to  a  Discussion  in  the  Section  of  Obstetric 
Medicine,  Fifty-first  Annual  Meeting  of  the  British  Medical  Association  [Brithh 
Medical  Journal,  vol.  i.,  1884,  p.  142). 


380  C.liSAREAN    SECTION    AND    TORRo's    OPERATION. 

in  that  disease  he  must  substitute  the  conditions  involved  in 
pregnancy  when  the  foetus  is  viable. 

The  patient  should  be  prepared  as  for  ovariotomy,  but  the 
waterproof  sheet  is  not  required.  The  incision  through  the 
abdominal  walls  must  be  of  a  fair  length,  at  least  four  inches, 
beginning  close  below  the  umbilicus,  for  in  relation  to  the 
incision  the  conditions  are,  in  this  case,  not  the  same  as  in 
ovariotomy.  The  walls  will  probably  be  found  to  be  very 
vascular,  as  in  cases  of  fibroid,  but  the  temporary  application 
of  pressure  generally  proves  sufficient  to  arrest  haemorrhage. 
"When  the  surface  of  the  uterus  comes  into  sight,  it  should  be 
examined  to  see  if  the  placental  attachment  lies  in  front.  This 
hap]3ened  in  Dr.  Grodson's  case.  "  The  uterus  being  exposed, 
its  anterior  surface  was  noticed  to  be  very  livid  in  appearance, 
suggesting  that  the  placenta  was  attached  to  the  anterior  wall, 
and  therefore  I  made  as  low  down  as  possible — that  is,  about 
the  junction  of  the  lower  with  the  middle  third — a  small 
incision  just  large  enough  to  admit  the  finger ;  a  gush  of  venous 
blood  occmred,  and  the  membranes  were  seen.  I  immediately 
inserted  the  tip  of  each  forefinger,  and  tore  the  womb  open 
transversely.  There  was  no  resistance.  The  membranes  were 
not  ruptm'ed  by  this  manipulation  ;  therefore,  knowing  the 
exact  position  of  the  foetus,  I  thrust  my  hand  through  them 
into  the  right  iliac  region,  and  seizing  the  neck  mthout  difii- 
culty,  extracted  the  child."  When  the  anterior  surface  of  the 
uterus  does  not  appear  to  be  livid,  then  a  freer  incision  may  be 
carefully  made  through  its  walls,  for  the  extraction  of  the 
foetus. 

Whilst  the  child  is  being  removed,  and  the  umbilical  cord 
di%"ided,  an  assistant  grasps  the  neck  of  the  uterus  with  his 
left  hand  introduced  into  the  pelvis,  so  as  to  control  hremor- 
rhage.  With  his  right  hand  he  slips  the  wire  of  a  Koeberl^'s 
serre-nccud  (described  at  pages  122,  295)  around  the  uterus  at 
the  level  of  the  os  internum,  taking  care  that  both  ovaries 
and  tubes  are  included — that  is,  that  they  both  lie  on  the 
distal  side  of  the  wire.  The  wire  is  now  made  tight.  Two 
pins  are  then  made  to  transfix  the  uterine  tissues  about  half 
an  inch  above  the  wire.  This  must  be  done  precisely  as  in 
hysterectomy    for   fibroids,    and   it    is   best    that    the    surgeon 


PORRO'S    OPERATION    AXD    ITS    MODIFICATIONS.  381 

should  do  it  at  this  stage,  and  not  after  the  uterus  is  cut  awaj. 
The  pins  will  serve  as  additional  landmarks  and  safeguards, 
and  there  cannot  he  too  many  such  aids  to  the  operator. 

The  surgeon  himself  having  ascertained  that  the  wii'e  is 
sufficiently  tight,  and  given  the  child,  if  alive,  into  proper 
hands,  now  amputates  the  uterus  above  the  pins.  The  intes- 
tines above  the  stump  should  be  at  once  guarded  by  a  large 
flat  sponge,  as  in  ovariotomy.  The  lower  part  of  the  abdo- 
minal incision  must  be  firmly  secm-ed  by  sutures  introduced 
as  in  other  abdominal  sections,  and  brought  close  to  the  stimip 
of  the  uterus,  below  the  wire.  It  is  not,  as  a  rule,  necessary 
to  apply  a  suture  to  the  walls  below  the  stump,  which  should 
be  pushed  down  to  the  lower  angle  of  the  wound.  Then  the 
sutures  are  applied  to  the  upper  part  of  the  wound,  the  flat 
sponge  removed,  and  the  peritoneum  carefully  freed  from  clots. 
Yery  little  blood  need  be  lost  during  this  operation. 

The  free  surface  of  the  stump  should  be  lessened  in  area 
in  the  manner  which  I  have  described  in  the  chapter  on 
Hysterectomy,  and  any  portion  of  it  which  must  be  left 
exposed  should  be  dusted  with  iodoform  or  solid  perchloride 
of  iron. 

The  operation  is  best  performed  with  full  antiseptic  pre- 
cautions. A  catheter  should  be  kept  in  the  bladder  during 
the  operation.  The  dressings  are  applied  as  after  hysterectomy. 
As  in  all  clamp  or  serre-noeud  cases,  much  care  must  be 
taken  to  draw  off  the  urine  regularly  every  six  hours,  else 
the  patient  will  be  sure  to  suffer  great  pain.  The  stump 
must  be  inspected  daily,  and  the  wire  tightened  whenever 
necessary.  The  stump  or  pedicle  will  become  slowly  detached, 
and  will  separate  entirely  in  about  three  weeks.  The  raw 
surface  left  after  separation  should  be  carefully  dressed  with 
iodoform  powder  or  carbolic  lotion. 

Operations  allied  to  Porro's. — There  are  several  opera- 
tions related  to  that  which,  according  to  Dr.  Grodson's  defini- 
tion, bears  the  name  of  Porro.  These  are  all  performed  on 
a  pregnant  uterus,  but  other-wise  differ  considerably  in  many 
respects  from  Porro's  operation. 

Of  these,  the  first  is  total'  amputation  of  a  pregnant  uterus, 
including  the  cervix. 


^82  CESAREAN    SECTION    AND    POKRo's    OPERATION. 

The  second  is  supra-cervical  amputation  of  the  uterus, 
and  removal  of  the  ovaries,  performed  during  pregnancy,  but 
before  the  foetus  is  viable. 

The  third  is  removal  of  a  fcetus  from  the  abdominal  cavity 
after  rupture  of  the  uterus,  and  amputation  of  the  ruptured 
uterus,  "^dth  removal  of  the  ovaries. 

Total  Amputation  of  a  Pregnant  Uterus,  or  *'  Porro- 
Freund's  Operation,"  has  been  successfully  performed  by 
Sii*  Spencer  Wells  in  one  case  where  I  was  present  and  had 
the  advantage  of  closely  inspecting  every  step  of  the  operation. 
It  has  been  described  more  than  once,*  but  deserves  notice  here, 
since  similar  cases  may  occur  in  the  futiu-e  and  may  recjuire 
similar  treatment. 

The  patient  was  a  woman  aged  thii-tj-'Seven,  suffering  from 
epithelioma  of  the  cervix,  and  six  months  pregnant.  She  had 
borne  five  childi'en  alread}'.  The  cervix  was  long  and  enlarged, 
the  OS  admitting  one  finger  easily  for  an  inch,  and  the  canal 
and  03  were  covered  with  an  exuberant  epitheliomatous  mass. 
After  several  less  severe  measures  had  been  proposed,  and 
rejected  for  various  reasons,  it  was  decided  to  remove  the 
uterus  entire. 

Full  Listerian  precautions  were  taken.  The  patient  was 
placed  in  ovariotomy  position.  It  was  considered  advisable 
to  keep  a  catheter  in  the  bladder,  and  an  opening  was  made 
for  it  in  the  waterproof  sheet  which  was  applied  to  the 
abdominal  walls  as  in  the  operation  for  removal  of  an  ovarian 
tumour.  The  vagina,  which  must  always  be  thoroughly 
washed  out  with  an  antiseptic  solution  before  any  proceeding 
of  this  kind,  was  plugged  A\ith  thymol  cotton  moistened  in  a 
tepid  1  per  cent,  solution  of  thymol.  The  abdominal  incision 
was  commenced  two  inches  above  the  umbilicus,  and  prolonged 
f.)r  six  inches  below  it.  The  pregnant  uterus  being  thus  freely 
exposed  was  lifted  out  of  the  upper  part  of  the  wound.  A 
flat  sponge  was  placed  over  the  intestines,  to  protect  them  from 
injury,  to  avoid  sudden  prolapse,  and  to  prevent  chilling  of  the 
peritoneal  cavity  by  the  action  of  the  spray.     This  arr.ingement, 

*  "Case  of  Excision  of  a  Gravid  Uterus  with  Epithelioma  of  the  Cervix  "  [Med.- 
Chir.  Trans.,  vol.  Ixv.,  1882).  Diagnosis  and  Surrjical  Treatment  of  Abdominal 
Tumours,  p.  171. 


"  porro-freitnd's  operation."  383 

described  by  the  operator,  was,  as  may  be  seen  from  what  I 
have  said  elsewhere  in  this  work,  in  accordance  with  the 
general  principles  of  abdominal  surgery.  The  edges  of  the 
upper  part  of  the  wound  were  then  united  by  four  silk 
sutures. 

In  order  to  secure  the  ovarian  vessels,  the  broad  hgament 
was  transfixed  below  the  ovary,  and  tied  with  strong  silk,  on 
both  sides.  The  ovaries  were  found  at  a  higher  level  and 
nearer  the  fundus  than  was  expected,  so  that  this  proceeding 
was  not  very  difficult.  Here  I  may  note  that,  in  pregnancy, 
the  uterine  appendages  are  drawn  up  high  out  of  the  pelvis, 
and  lie  symmetrically*  on  each  side  of  the  gravid  uterus. 

The  bladder  was  then  dissected  from  the  anterior  surface  of 
the  uterus.  The  thin,  tense  walls  of  that  organ  suddenly  gave 
way.  The  membranes  were  ruptured,  and  the  foetus  extracted, 
the  cord  being  tied  and  cut.  The  connections  between  the 
uterus  and  the  vagina  were  separated,  the  operator  cutting 
close  round  the  cervix,  and  securing  by  pressure-forceps  all 
bleeding  vessels  as  they  were  divided.  In  this  manner  the 
entire  uterus,  with  the  cancerous  mass  in  the  cervix,  was 
removed.  The  forceps  were  taken  off  successively,  and  every 
bleeding  vessel  tied  with  carbolizecl  silk.  The  vaginal  plugs 
were  taken  out,  and  the  opening  in  the  vagina  and  the  edges 
of  the  divided  broad  ligaments  were  united  with  silk  sutures. 
The  pelvis  was  cleaned  with  sponges.  Silk  sutures  were 
applied  to  the  lower  part  of  the  abdominal  wound,  and  then 
the  entire  wound  was  closed.  The  abdomen  was  lastly 
covered  with  dressings,  as  in  a  case  of  ovariotomy. 

This  operationt  was  completed  within  an  hom\  The  fcetus 
was  of  about  the  sixth  month.  The  abdominal  wound  opened 
on  the  eighth  day,  through  frequent  vomiting,  but  was 
readily  closed  again.  The  patient  returned  to  her  home  on 
November  21st,  1881,  a  calendar  month  after  the  operation. 
She  enjoyed  good  health  for  eight  or  nine  months,  though  in 
February,  1882,  a  suspicious  thickening  was  discovered  in  the 

*  See  p.  292. 

t  Syoteniatic  writers  f^peak  of  it  as  "  Porro-Freuml's  operation/'  as  it  is  a 
combination  of  Porro's  operation  with  total  extirpation  of  the  cancerous  uterus 
as  practised  by  Freund  (see  p.  318,  7iote). 


y84  C-ESAREAX    SECTION    AND    PORRO's    OPERATION. 

vaginal  cicatrix.  Thirteen  months  after  the  removal  of  the 
uterus  she  died,  a  large  mass  having  formed  in  the  left  iliac 
fossa. 

In  this  case  I  examined  the  uterus  after  its  removal,  and 
it  appeared  to  me  that  the  whole  of  the  area  of  visible 
cancerous  disease  had  been  taken  away.  Some  of  the  broad 
ligament  left  behind  probably  contained  cancerous  elements 
{see  page  317).  The  result  of  this  case  certainly  tended  to 
justify  the  operation.  Delivery  through  the  cancerous  os 
after  three  months  of  further  progress  of  the  mahgnant 
disease  would  have  entailed  great  risks.*  As  it  was,  those 
three  months,  or  at  least  the  last  two,  were  spent  in  comfort, 
to  which  may  be  added  another  month  not  spent  in  childbed, 
and  a  few  more  months  of  relative  ease  while  the  patient 
still  remained  in  good  general  health. 

Supra- vaginal  Hysterectomy  during  Pregnancy. — 
The  second  variety  of  operation  allied  to  that  known  as  Porro's 
is  supra-vaginal  and  supra-cervical  amputation  of  the  uterus 
and  removal  of  the  ovaries,  performed  during  pregnancy,  but 
before  the  foetus  is  viable. 

This  operation  practically  implies  removal  of  a  pregnant 
uterus  affected  with  fibroid  disease.  It  is,  however,  conceivable 
that  it  might  be  done  for  other  complications. 

Pregnancy  dming  fibroid  disease  may  be  overlooked,  even  by 
the  experienced.  There  may  be  fi'equent  discharges  of  blood 
from  the  vagina,  mistaken  for  menstruation;  the  abdominal 
enlargement  may  be  attributed,  yqvj  naturally,  to  the  fibroid 
tumour  alone;  besides,  the  patient,  probably  feeling  sensations 
different  from  those  experienced  in  previous  pregnancies,  may 
fail  to  direct  the  surgeon's  attention  to  matters  which  would 
suggest  pregnancy.  These  matters,  on  the  other  hand — enlarge- 
ment of  the  breasts,  for  example, — may  be  duly  noted  by  the 
surgeon,  yet  attributed  to  other  causes.  Oozing  from  the  nipple 
is  observed  in  some  cases  of  fibroid  disease  where  there  is  no 
pregnancy.  Lastly,  as  in  many  other  diseases,  it  has  been 
taken  for  granted  that  undersized,  repidsive,  and  otherwise  ill- 
conditioned  single  females  are  never  exposed  to  those  unfavour- 

*  Hence  this  operation  differs  in  principle  from  total  extirpation  of  the  non- 
pregnant uterus. 


REMOVAL    OF    A    PREGNANT    FIBROID    UTERUS.  385 

able  ethical  conditions  which  involve  pregnancy.     This  has  led 
to  error,  in  one  case  at  least,  as  I  am  aware. 

Removal  of  a  pregnant  fibroid  nterus  is  a  very  difficult  and 
dangerous  operation.  When  it  is  performed  late  in  an  undiag- 
nosed pregnancy  the  alterations  in  the  cervix  interfere  with  a 
firm  application  of  the  serre-noeud  wire,  and  intra-peritoneal 
treatment  of  the  pedicle  will  be  yet  more  hazardous.  Moreover, 
the  discovery  of  an  unexpected  fcetus  will  disconcert  even  a 
strong-nerved  operator.  I  have  known  disastrous  consequences 
to  follow  in  two  cases.  In  a  third,  at  which  I  assisted,  the 
patient  was  a  miserable,  sickly  single  woman  aged  thirty-two, 
who  had  been  more  or  less  confined  to  her  bed  for  a  year.  A 
solid  oblong  tumour  extended  nearly  to  the  ensiform  cartilage, 
and  the  abdominal  incision  had  to  be  extended  two  inches  above 
the  umbilicus.  On  extracting  the  tumour  from  the  wound,  a  tense 
globular  swelling,  looking  like  a  cricket  ball,  was  observed  on  its 
lower  aspect ;  its  walls  were  much  paler  than  the  surface  of  the 
growth.  This  swelling  proved  to  be  the  uterus.  Dr.  Bantock 
passed  the  wire  of  a  Koeberle's  serre-noeud  round  the  cer\dx,  the 
pins  were  applied,  as  in  an  uncomplicated  hysterectomy,  and 
the  tumour  and  uterus  were  cut  away.  As  the  knife  passed 
through  the  uterine  tissue,  a  dead  foetus,  three  inches  long, 
with  placenta,  escaped.     Recovery  was  rapid. 

Mr.  Knowsley  Thornton  successfully  operated,  in  1882,  on  a 
case  where  pregnancy  at  four  and  a  half  months  was  evident, 
and  a  large  fibroid  gave  great  distress.  Sir  Spencer  Wells 
performed  a  true  Porro's  operation  last  May  (1887),  removing 
a  pregnant  fibroid  uterus  close  upon  term.  Both  mother  and 
child  were  saved. 

In  short,  when  this  operation  is  decided  upon,  before  or 
during  abdominal  section,  it  must  be  performed  jDrecisely  as  an 
ordinary  hysterectomy  for  fibroid  disease,  but  with  more  than 
usual  deliberation.  When,  on  opening  the  abdominal  cavity, 
unsuspected  pregnancy  is  discovered,  and  the  fibroid  growth 
proves  to  be  small  and  not  in  a  position  to  interfere  with 
delivery  at  term,  it  will  be  advisable  to  close  the  wound  and  wait. 

No  general  rules  can  be  laid  down  for  these  grave  cases,  and 
much  will  depend  upon  circumstances  and  on  the  surgeon.  They 
demand  considerable  experience  in  abdominal  surgery. 

c  c 


386  c.t:sarean  section  and  porro  s  operation. 

Supra-vaginal  Hysterectomy  for  Rupture  of  the 
Uterus :  Removal  of  the  Foetus  from  the  Abdominal 
Cavity. — The  results  of  this  bold  proceeding  have  proved 
highly  unsatisfactory.  I  have  noted  some  of  the  features  of 
ruptui'e  of  the  uterus  in  the  observations  on  Ceesarean  section 
{page  377).  The  rent  being  usually  near  the  cervix,  it  is 
placed  in  the  situation  most  unfavourable  for  the  safe  applica- 
tion of  the  wire  of  the  serre-noeud.  Should  it  be  near  the 
fundus,  and  should  the  sm-geon  determine  upon  this  operation, 
he  must  secure  the  uterus  by  means  of  an  elastic  ligature 
directly  the  abdominal  cavity  is  opened,  remove  the  foetus,  and 
then  proceed  as  in  Porro's  operation  properly  so  called. 

Laparo-elytrotomy,*  or  Thomas's  Operation. — This 
operation  consists  in  cutting  down  on  the  upper  part  of  the 
vagina  through  an  incision  above  Poupart's  ligament,  the 
peritoneum  being  pushed  aside.  The  foetus  is  then  delivered 
through  the  wound.  Thus  the  peritoneal  cavity  is  not  opened, 
and  the  foetus  has  not  to  pass  through  the  pelvis,  which,  it 
is  to  be  assumed,  is  contracted  in  cases  where  this  operation 
is  undertaken.  Recently  Dr.  Gaillard  Thomas  has  practised 
and  advocated  it,  and  has  been  followed  by  several  American 
and  British  operators.  Up  to  1885  the  statistical  results  were 
the  saving  of  six  mothers  in  twelve  operations  ;  but  as  Dr. 
Lusk  points  out,  the  cases  were  mostly  in  the  hands  of  excep- 
tionallj'  good  and  experienced  operators.  Dr.  Playfair  believes 
that  "the  operation  has  a  great  future  before  it."t  British 
operators  are  not  likely  to  adopt  it,  at  present,  in  preference 
to  Porro's  operation  or  Caesarean  section.  Its  chief  merit  lies 
apparently  in  the  fact  that  the  uterus  is  not  wounded ;  as  for 
the  peritoneum,  few  operators  now  fear  to  open  its  cavity. 

*  "  AaTTctpci,  Ion.  XaTrdpyj,  the  soft  part  of  the  body  between  the  ribs  and  hips, 
the  flank,  loins.  Latin,  ilia." — A  Lexicon  abridged  from  Liddell  and,  Scott's. 
"Laparo"  is,  therefore,  fairly  correct  in  this  case,  wlien  we  remember  the  situa- 
tion of  the  abdominal  incision. 

+  A  Trmtitc  on  the  Science  and  Practice  of  Midwifery.     Sixth  edition.     1886. 


38- 


CHAPTEE   XV. 

OPERATIONS   FOR  THE    REPAIR  OF    RUPTURED    PERINEUM,   AND 
FOR  THE   RELIEF   OF   PROLAPSUS   UTERI. 

Kupture  of  the  Perineum. — This  injury  is  so  frequent, 
that  the  operation  for  its  repair  is  the  commonest  and  best 
known  plastic  procedui'e  in  the  neighbourhood  of  the  female 
organs.    . 

In  the  large  majority  of  cases,  rupture  of  the  perineum 
takes  place  dming  labour.  The  perineum  is  exposed  to  con- 
siderable violence  during  the  expulsion  of  the  child  from  the 
vagina,  especially  in  certain  unfavourable  presentations.  The 
hands  and  instruments  of  the  obstetrician  may  cause  the  injury. 
The  anterior  part  of  the  perineum  may  alone  be  torn,  whilst 
in  other  cases  the  rupture  is  complete  so  as  to  involve  the 
sphincter  ani.  In  very  rare  instances,  the  vaginal  wall  has 
been  torn  above  the  vulva,  and  the  child  forced  through  the 
rent  and  out  of  the  middle  of  the  perineum,  making  for  itself 
a  rupture  through  the  perineal  integuments  which  does  not 
reach  either  forwards  to  the  ^Tilva  or  backwards  to  the  anus. 
This  condition  is  termed  "  central  rupture  of  the  perineum." 
It  is  now  generally  agreed  that  when  a  rupture  of  the  perineimi 
is  discovered  after  labour  it  should  be  sewn  up  at  once.  This 
it  appears  can  often  be  readily  and  successfully  performed,  even 
when  the  sphincter  ani  is  much  involved.  When  that  compli- 
cation does  not  exist,  there  can  be  no  doubt  that  the  perineimi 
should  be  repaired  directly.  In  cases  where  it  does  exist  a 
successful  immediate  operation  saves  the  patient  from  certain 
misery,  and  economizes  the  time  which  she  must  spend  in  the 
sick-bed.     Yet  when  the  laceration  extends  far  into  the  rectum 


388  REPAIR    OF    RUPTURED    PERINEUM. 

the  operation  dii-eetly  after  labour  may  be  very  difficult,  and 
the  wounds  may  heal  badly.  Hence,  after  it  has  been  performed, 
the  parts  must  be  examined  from  time  to  time  diuing  recovery, 
and  the  surgeon  must  make  sure  that  the  sphincter  regains  its 
functions,  nor  must  he  be  discouraged  should  a  fresh  operation 
be  necessary. 

Dr.  Gaillard  Thomas  has  observed  that  for  laceration  of  the 
perineum  there  is  but  one  cause — partm-ition.  It  may  occur, 
however,  diu-ing  the  instrumental  delivery,  not  of  a  child,  but 
of  a  fibroid  polypus,  or  a  sessile  fibroid  tumour  shelled  out  of 
its  capsule.  The  rent  may  then  be  caused  by  one  blade  of  a 
large  volsella,  but  I  have  seen  it  produced  in  a  middle-aged 
single  woman,  by  the  simple  dilatation  of  the  posterior  part  of 
the  vulva  during  careful  extraction  of  the  tiunour  piece  by  piece. 
The  laceration  in  this  case  was  slight,  and  extensive  damage 
can  always  be  prevented  by  avoiding  hm-ry  in  the  extrac- 
tion of  the  tumour,  and  by  removing  small  fragments  only 
at  a  time. 

Anatomy  of  the  Perineum. — The  temi  perineum  is  not 
understood  precisely  in  its  dissecting-room  sense,  when  a  ruptured 
perineum  is  signified.  The  integuments  between  the  vulva  and 
the  anus,  the  perineal  body  and  the  vaginal,  and  often  the  anal 
mucous  membranes  are  torn  when  the  perineum  is  ruptured. 
The  sphincter  ani  may  or  may  not  escape  damage  ;  the  sphincter 
vaginae,  it  would  appear  at  fii'st  sight,  cannot  escape  laceration. 
This  muscle,  however,  is  of  less  importance  than  was  formerly 
supposed. 

A  pjTamidal  collection  of  connective-tissue  fibres  chiefly 
elastic,  with  its  apex  upwards,  lies  beneath  the  integument  of 
the  true  perineum,  and  extends  between  the  walls  of  the  rectum 
and  vagina.  This  is  the  perineal  body  described  by  Savage. 
It  acts  as  a  point  of  attachment  for  several  muscles,  and  keeps 
the  canal  of  the  anus  well  back,  also  preventing  the  anterior 
wall  of  the  rectum  from  bulging  into  the  vagina.  The  i)erineal 
body  protects  the  soft  parts  inferiorly  and  posteriorly  during 
labour.  Berry  Hart  compares  it,  in  this  respect,  to  the  brass- 
bound  edge  of  a  doorstep.  On  the  other  hand,  this  body  is  not 
the  main  support  of  the  vagina,  uterus,  and  abdominal  viscera 
above  them.     Even  if  it  were  made  of  dense  bone,  it  could  not 


PATHOLOGY   OF    RUPTURED    PERINEUM.  38f> 

prevent  them,  under  unfavourable  circumstances,  from  sliding 
down  in  front  of  its  boundaries.* 

Pathology  of  Ruptured  Perineum,  and  Principles 
of  Treatment. — The  inconvenience  of  ruptured  perineum 
hardly  needs  explanation.  The  relations  of  the  recto-vaginal 
septum  are  disturbed,  the  attachments  of  several  important 
muscles  displaced,  and  the  sphincter  ani  is  often  torn.  No 
doubt  the  perineal  body  takes  a  share  in  the  support  of  the 
parts  above  it,  though  not  nearly  to  such  an  extent  as  was 
formerly  supposed.  The  frequent  coincidence  of  prolapse  of 
the  uterus,  however,  is  not  to  be  entirely  explained  by  the 
rupture  of  the  perineum. 

It  does  not  require  much  argument  to  prove  that  the  way  to 
relieve  the  symptoms  of  ruptured  perineum  is  to  repair  the 
rupture,  and  experience  proves  that  when  properly  repaired, 
the  relief  is  perfect.  Hence  surgical  considerations  are  the 
most  important  in  respect  to  this  subject.  Distinguished 
authorities  in  all  parts  of  the  civilized  world  have  studied  the 
anatomy  and  surgery  of  the  perineum ;  but  there  is  no  room 
in  these  pages  for  a  fair  summary  of  their  conclusions.  Many 
practical  surgeons  have  successfully  operated  on  large  series 
of  cases  of  ruptured  perineum,  guided  by  one  principle,  the 
recognition  of  the  necessity  of  sewing  up  the  parts  so  that 
they  should  hold  together  and  heal,  and  ensuring  that  the 
repaired  parts  do  not  break  down  afterwards.  The  innumerable 
variations  in  the  details  of  this  operation,  which  is  often  termed 
perineorrhaphy,  are  nearly  all  founded  on  this  principle.  One 
operator  prefers  one  kind  of  sutui-e,  another  adopts  a  partially 
or  totally  novel  line  of  practice.  Again,  surgeons  differ  greatly 
in  their  opinions  as  to  the  best  kind  of  after-treatment — that 
is  to  say,  as  to  the  best  manner  of  allowing  a  strong  cicatrix 
to  develop,  with  as  little  risk  as  possible  from  the  passage  of 
ffeces  in  its  immediate  neighbourhood. 

The  surgeon  should  remember  that  when  the  solid  pjTamid 
of  more  or  less  elastic  tissues  forming  the  perineum  is  torn 
through,  the  parts  originally  lowest  and  most  central — that  is, 

*  For  fuller  details  concerning  the  anatomy  of  the  perineum  and  other  scientific 
considerations  relating  to  that  region,  the  reader  should  consult  Dr.  Savage's 
Atlas  and  Dr.  l\Iatthews  Duncan's  Fai)ers  on  the  Female  Perinetim. 


390  REPAIR    OF    RUPTURED    PERIXEUM. 

along  the  raphe — fl}^  more  widely  asunder  than  the  remainder  of 
the  lacerated  tissues,  and  constitute  the  lateral  boundaries  of 
the  raw  surface  formed  by  the  injury.  The  upper  limit  of  the 
laceration  mil  descend  so  as  to  occupy  a  central  position  along 
the  raw  surface,  on  a  plane  almost  as  low  as  that  of  the  lateral 
boundaries.  The  raw  surface  itself  will  represent  the  deep 
tissues  torn  thi'ough  between  the  lower  and  the  upper  limit  of 
the  laceration,  and  gaping  apart  in  two  halyes.  When  sutm'es 
haye  been  passed  behind  the  two  halyes  of  the  raw  siu-face, 
emerging  beyond  its  lateral  boundaries,  the  two  halyes  will  be 
brought  together  when  the  threads  are  pulled  tight ;  the  lateral 
boundaries  will  be  drawm  do^mwards  and  inwards  till  they 
meet  along  the  middle  line,  and  what  was  the  middle  line  of 
the  raw  siu'face  will  lie  anatomically  uppermost.  Thus  the 
parts  will  be  restored  to  their  normal  position.*  Anteriorly  and 
posteriorly  lie  the  vaginal  and  anal  mucous  membranes.  If 
torn,  here,  again,  the  uppermost  limit  of  the  laceration  will  lie  in 
the  middle  of  the  torn  edge.  Certain  special  precautions,  how- 
ever, are  needed  in  sewing  these  parts  together,  lest  mucous 
membrane  should  be  forced  between  the  edges  of  the  line  of 
sutui^e. 

Preparation  for  Operation  on  Ruptured  Perineum. 
— The  surgeon  has  not  onlj'  to  make  and  to  promote  the  heal- 
ing of  a  wound,  but  he  must  ensure  the  formation  of  a  strong 
cicatrix.  Hence  he  should  attend  to  the  patient's  general 
health,  and  make  siu-e  that  the  bowels  are  in  a  satisfactory 
condition.  Dr.  Graillard  Thomas  gives  good  advice  on  this 
subject  in  his  Practical  Trcatke  on  the  Dineascs  of  Women.  He 
observes  that  the  intestinal  canal  is  about  twenty-five  feet  long, 
and  keeps  faecal  masses  stored  up  in  it  for  months.  Therefore, 
he  recommends  that  two  entire  weeks  should  be  devoted  to  com- 
plete evacuation  of  all  scybalous  masses.  This  may  be  effected 
by  the  frequent  administration  of  purgatives,  such  as  rhubarb 
or  colocynth,  not  so  as  to  produce  continual  pm'ging,  but  so  as 
to  open  the  bowels  twice  every  twenty-four  hom's.  The  do.se 
must  be  given  according  to  the  patient's  susceptibility  to  purga- 
tives.    An  enema  should  always  be  administered  shortly  before 

*  These  changes  of  plane  and  position  are  explained  in  the  diagrams  illustrating 
the  operation  for  the  restoration  of  a  complete  rupture  of  the  perineum. 


PREPARATION THE    OPERATION.  391 

operation.  Once  more,  I  repeat,  the  purgative  must  not  be 
given  so  frequently  or  in  such  large  doses  as  to  set  up  diarrhoea, 
as  that  condition  may  cause  serious  inconvenience  during  opera- 
tion. 

Great  care  must  be  taken  to  relieve  any  symptoms  of  haemor- 
rhoids or  discharges  from  the  uterus  and  vagina.  Internal 
piles  are  a  frec[uent  complication  of  ruptured  perineum,  and  the 
trouble  which  they  cause  is  mixed  up  with  the  inconvenience 
produced  by  the  rupture.  Owing  to  the  destruction  of  the 
entirety  of  the  sphincter,  some  of  the  most  distressing  sub- 
jective symjDtoms  of  piles  will  be  absent;  but  the  presence  of 
hsemorrhoidal  swellings  will  cause  inconvenience  to  the  operator, 
and  they  always  imply  a  more  or  less  unhealthy  state  of  the 
surrounding  mucous  membrane.  When  they  exist,  then,  it  is 
advisable  to  pay  particular  attention  to  the  rectum,  guarding  it 
from  prolapse  as  much  as  possible,  and  keeping  it  supported 
(before,  not  after  the  operation,  be  it  strictly  understood)  by  a 
T-bandage. 

Discharges  from  the  genital  tract  may  prove  very  prejudicial 
to  the  healing  process.  When  they  occur  in  acute  local  dis- 
orders, the  latter  must,  of  course,  be  cured  before  any  operation 
is  attempted.  When  they  are  unaccompanied  by  evidence  of 
uterine,  ovarian,  or  tubal  disorder,  they  are  generally  associated 
with  some  visceral  disease,  such  as  emphysema  and  bronchitis  or 
hepatic  congestion.  In  these  cases  the  discharge  is  none  the 
less  mischievous  because  it  does  not  represent  a  local  disease. 
In  plethoric  women  of  intemperate  habits,  it  may  be  very  hard 
to  check.  Hot- water  injections  and  the  application  of  cotton- 
wool plugs,  soaked  in  glycerine,  to  the  cervix  will  generally  do 
much  good.  In  these  cases,  not  only  is  the  discharge  irritant, 
but  the  wounds  do  not  tend  to  heal  quickly.  It  is,  therefore, 
just  among  such  cases  that  failures  are  most  frec[uent. 

The  Operation  for  Rupture  including  the  Sphincter 
Ani. — I  have  no  intention  of  attempting  to  describe  all  the 
varieties  of  operations  for  the  cm*e  of  ruptured  perinemn.  I 
shall  confine  myself  to  the  description  of  two  or  three  methods 
which  at  present  commend  themselves  to  different  operators, 
without  critically  discussing  their  relative  merits. 

I  believe  that  the  simplest  method  for  the  beginner  is  that 


392  REPAIR  OF  RUPTURED  PERINEUM. 

whieli  is  practised,  on  modifications,  to  a  certain  extent,  of 
details  introduced  by  previous  operators,  by  Dr.  Bantoek, 
and  described  in  bis  work  On  the  Treatment  of  Biiptiire  of  the 
Female  Peyineum.  This  method  is  widely  adopted  by  other 
experienced  specialists.  I  find  that  it  is  followed  by  excellent 
results.  For  these  reasons  I  tliink  it  best  to  give  the  method 
the  first  place  on  the  list  of  those  which  I  now  propose  to 
describe.  Dr.  Bantoek  has  kindly  revised  the  following  account 
of  the  operation,  as  he  has  altered  certain  details,  especially 
those  which  concern  after-treatment,  since  the  publication  of 
his  work  on  the  subject. 

I  must  first  remark  that  di\dsion  of  the  sphincter  ani,  or 
incisions  through  the  integument  on  each  side  of  the  line  of 
union  to  relieve  tension,  are  considered  unadvisable  by  most 
living  authorities. 

The  patient  must  be  placed  in  the  lithotomy  position  directly 
she  is  fairly  under  the  influence  of  the  ansesthetic.  As  in 
ovariotomy,  the  preparations  for  fixing  her  in  the  proper 
postm-e  should  not  be  commenced  until  she  is  no  longer  in  a 
condition  to  observe  and  to  be  frightened  by  them.  A  Clover's 
crutch  (page  132)  should  always  be  employed,  if  possible,  as  it 
greatl}^  economizes  assistance.  The  parts  are  washed,  and  the 
hairs  of  the  posterior  part  of  the  vulva  and  the  perineum  are 
shaved  away  or  cut  close.  A  large  pan  or  footbath  should  lie 
vertically  below  the  parts,  so  as  to  catch  blood,  forceps,  or  water 
used  for  cleansing  purposes.  The  labia  are  held  apart.  This 
is  best  done  b}'-  a  different  person  on  each  side.  The  fingers  of 
one  hand  can  hold  back  the  greater  labium  by  di-agging  on  the 
integuments  external  to  it,  whilst  the  palm  of  the  same  hand 
presses  back  the  buttock.  The  two  assistants  will  each  have  a 
hand  free  for  holding  sponges  and  instruments.  They  must 
stand  so  as  to  keep  well  out  of  the  operator's  light. 

Sometimes  the  area  for  denudation  is  well  marked  out  by 
a  wide  sm'face  of  pale  cicatricial  tissue,  but  this  is  not  the  rule. 
The  operator  makes  an  incision  with  a  small  scalpel  on  each 
side  (Fig.  139,  a  tj  and  c  d),  from  before  backwards,  beginning 
at  the  point  where  the  lesser  labium  is  lost  on  the  inner  aspect 
of  the  greater,  and  ending  at  the  level  of  the  anal  orifice,  which 
in  severe  cases  hes  wide  open. 


OPERATION  FOR  COMPLETE  RUPTURE. 


393 


The  posterior  extremities  of  these  two  incisions  are  now 
united  hy  a  third,  which  passes  across  the  hne  of  junction 
between  the  vaginal  and  rectal  mucous  membranes  (Fig.  139,  h, 
e,  d).  The  best  way  to  make  this  incision  is  to  hold  the  scalpel 
with  the  edge  of  the  blade  uppermost,  and  to  enter  the  point  at 
the  left  extremity  of  the  line  between  the  mucous  membranes. 
The  point  is  then  pushed  under  the  tissues  along  the  line  to  its 
right  extremity,  so  that  the  edge  of  the  blade  cuts  through 
them.      The   rectal  mucous  membrane  often  bulges,  and  maj 


Fig.  139. — Operation  for  Ruptured  Perixeum. 
The  raw  surface.     (Bantock.) 

present  hsemorrhoidal  dilatations.  When  such  is  the  case,  the 
edge  of  the  protruding  mucous  membrane  must  be  seized  by 
a  long-bladed  spring-forceps,  which  is  then  allowed  to  hang 
down,  thereby  dragging  the  mucous  membrane  out  of  the 
operator's  way,  or  it  may  be  held  by  an  assistant.  During  all 
these  manoeuvres,  the  bleeding,  sometimes  very  free,  must  be 
checked  by  sponges  wrung  out  in  hot  water  and  mounted  on 
holders.  Any  spouting  artery  should  be  secm'ed  by  pressure- 
forceps,  or  by  torsion  if  the  hsemorrhage  be  considerable  and 
the  vessel  large.     In  many  cases  no  vessel  will  recjuii^e  ligatui'e. 


394  REPAIR    OF    Ri:PTURED    PERINEUM. 

provided  that  the  operation  is  not  done  in  a  hnrry,  and  that  the 
pressure-forceps  are  not  removed  until  the  perineum  is  closed. 
It  is  always  best  to  avoid  ligatiu-es,  if  possible. 

The  mucous  membrane  must  now  be  dissected  up,  the  limits 
of  the  area  thus  denuded  being  the  longitudinal  incisions 
a  h,  c  d  laterally,  the  transverse  incision  h  e  d  posteriorly,  and 
the  line  a  f  c  anteriorly.  The  vaginal  mucous  membrane  is 
dissected  up,  from  behind  near  h  e  d,  forwards  as  far  as  a  f  c. 
None  of  it  must  be  cut  away,  for  as  it  is  raised  by  dissection 
it  will  retract.  If  this  part  of  the  vaginal  mucous  membrane 
be  redundant,  or  the  vaginal  wall  prolapsed,  an  assistant  should 
hold  up  its  cut  edge,  by  the  aid  of  a  long-toothed  forceps.  For 
this  dissection  scissors  are  perhaps  preferable  to  the  scalpel,  as 
there  is  less  bleeding  when  the  former  instrument  is  used.  On 
the  other  hand,  the  scalpel  is  easier  to  handle. 

When  the  dissection  is  complete,  so  that  the  mucous  mem- 
brane has  retracted  up  to  the  limit  indicated  hj  a  /  c,  the 
parts  will  assume  the  appearance  represented  in  Fig.  139.  Two 
triangles  of  raw  tissue  will  be  formed.  By  closing  on  itself  the 
line  b  e  d,  so  that  the  raw  edges  h  c,  d  e  come  in  contact,  the 
anus  will  be  closed.  Then,  by  bringing  together  the  surfaces 
of  the  triangles  which  gape  so  widely  apart,  the  perineum  will 
be  restored.  Before  the  application  of  the  sutures,  the  parts  lie 
gaping,  the  tissues  in  the  middle — that  is,  between  /  and  e — 
being  almost  as  low  down  as  the  plane  of  the  limiting  incisions 
a  b,  c  d.  "When  the  sutures  are  brought  together,  the  lines 
a  h,  c  d  will  be  di'awn  inwards  and  meet  each  other,  forming  the 
middle  line  of  the  perineum  ;  ,/  e  will  be  high  up  in  the  recto- 
vaginal septum,  and  the  raw  surfaces,  instead  of  looking  almost 
directly  downwards,  and  only  meeting  along  the  middle  line, 
vnW.  look  inwards,  touching  each  other  along  the  vertical  mesial 
plane  of  the  perineal  body. 

Such  is  the  problem  to  be  solved.  This  must  clearly  be 
understood  by  the  operator.  The  patulous  condition  of  the 
parts  and  the  bulging  mucous  membrane  often  confuse  the 
inexperienced. 

The  mucous  membrane  of  the  anus  is  first  united — that  is, 
the  lines  e  b,  e  d  are  brought  together.  Silkworm-gut  is  very 
useful  for  this  purpose.      Each  sutm-e  must  be  threaded  on  two 


OPERATION  FOR  COMPLETE  RUPTURE. 


395 


small  curved  needles,  one  at  each  end.  Then  one  needle  is 
seized  between  the  blades  of  a  holder,  and  passed  through  the 
raw  surface  close  to  the  free  edge  of  the  mucous  membrane  just 
below  e,  towards  J,  transfixing  the  membrane  close  to  its  edge,* 
so  that  one  end  of  the  thread  is  brought  out.  The  other  needle 
is  made  to  bring  the  opposite  end  of  the  thread  out  through 
the  rectal  mucous  membrane  below  e,  towards  d.  Three,  four,  or 
more  sutures  are  thus  inserted,  from  above  downwards  (Fig.  140). 
The  needle-holder  must  always  be  used  for  the  application  of 
sutures ;  if  the  fingers  alone  be  employed,  the  needles  will  be 
difficult  to  pass,  and  the  parts  may  get  briiised  by  the  knuckles. 


Fig.  140. — Opekatiox  for  Ruptured  PEEiNEUir. 
The  anal  sutures.     {Bantock.) 

The  needle  should  always  be  passed  in  the  manner  just  de- 
scribed, as  inversion  of  mucous  membrane  into  the  wound  and 
faulty  apposition  are  thereby  most  readily  avoided.  The  sutures, 
when  all  inserted,  are  drawn  together,  and  after  a  good  washing 
of  the  parts  by  a  jet  of  cold  water  from  a  Higginson's  syringe, 
the  ends  are  tied  and  cut  short.  When  this  is  done,  the  edges 
b  e  and  d  e  (Fig.  139)  will  be  brought  together,  as  in  Figs 
141,  142. 

*  It  is  a  great  mistake  to  introduce  tlie  needle  too  far  from  the  edge.  Such  a 
practice  results  in  the  inclusion  of  portions  of  mucous  memlirane  between  the 
sutures,  and  consequent  failure  of  union  of  more  or  less  of  tlie  wound. 


396  REPAIR    OF    RUPTURED    PERINEUM. 

The  perineum  itself  has  now  to  be  restored.  For  this  object 
a  surgeon  not  used  to  plastic  operations  will  find  a  mounted 
needle  with  a  strong  curve  most  satisfactory.  The  use  of 
a  free  needle  and  a  needle-holder  for  this  purpose  requires 
practice.  A  well-curved  handled  needle,  eyed  near  the  point, 
is  the  most  satisfactory  kind  of  free  needle.  As  in  the  case 
of  the  rectal  sutm-es,  silkworm-gut  is  the  best  material. 

The  needle,  whether  mounted  or  not,  must  be  entered  about 
a  quarter  of  an  inch  from  the  margin  of  the  longitudinal 
incision,  c  cl  (Fig.  139),  on  the  left  side,  and  about  the  same 
distance  in  front  of  the  anal  orifice.  It  is  then  pushed  under 
the  raw  surface  till  it  emerges  at  a  corresponding  point  external 
to  the  longitudinal  incision,  a  h  (Fig.  139),  on  the  opposite  side; 
then  the  suture  thi^ead  is  applied  and  the  needle  withdrawal, 
leaving  the  thread  in  its  track.  The  surgeon  keeps  his  left 
forefinger  in  the  rectum,  and  watches  the  raw  surfaces  as  he 
passes  the  needle  through  the  tissues  and  -uathdi-aws  it,  so  that 
he  can  make  sure  that  no  part  of  the  suture  hes  in  the  rectum 
or  crosses  the  wound.  The  remaining  sutures  are  then  applied 
in  the  same  manner.  About  five  ^vill  be  sufficient.  The  higher 
sutui'es  should  be  passed  through  the  edges  of  the  vaginal 
mucous  membrane,  and  made  to  cross  between  them  in  the  open 
— that  is,  not  under  the  tissues  (Fig.  141). 

Sometimes  much  prolapse  of  the  rectum,  with  redundancy  of 
the  vaginal  mucous  membrane,  exists.  It  is  then  advisable  to 
dissect  away  a  wedge  of  the  mucous  membrane,  beginning  at 
the  point,/'  (Fig.  139),  tind  to  unite  the  edges  after  the  manner 
adopted  for  the  rectum  (Fig.  142).  The  amount  of  tissue 
dissected  away  will  differ  according  to  the  degree  of  redundancy 
of  the  mucous  membrane. 

The  sutui'es  having  been  inserted,  the  opposite  ends  must  be 
held  up  by  the  assistant ;  he  will  find  it  advantageous  to  secure 
the  ends  by  the  aid  of  pressm-e-forceps,  as  I  have  recommended 
in  the  chapters  on  Ovariotomy  (page  236).  Then  he  can  hold 
the  sutures  loosely,  but  well  upwards  out  of  harm's  way.  The 
operator  sponges  the  wound  and  washes  it  out  by  syringing 
as  before.  "^I^Tien  the  bleeding  has  ceased,  the  crutch  must  be 
taken  off  and  the  patient's  knees  brought  together. 

The  operator  now  holds  the  ends  of  all  the  deep  sutures  in 


OPERATION  FOR  COMPLETE  RUPTURE. 


39' 


his  right  hand  and  draws  them  towards  himself.     He,  at  the 
same   time,  presses   gently   on   the   recto-vaginal    septum    by 


Fig.  141. — Operation  for  Ruptured  Perineum. 
The  perineal  sutures.     Anal  sutures  tied.     {Bantock.) 


Fig.  142. — Operation  for  Ruptured  Perineum. 
Sutures  applied  to  vaginal  mucous  membrane.     [Bantock.) 

introducing  the  left  forefinger  into  the  vagina,  so  as  to  ensure 
proper   adaptation   of   the   raw  surfaces.     Then   the   assistant 


398  REPAIR  OF  RUPTURED  PERINEUM. 

takes  charge  of  the  ends  of  the  sutures,  excepting  the  lowest, 
holding  them  firmly,  but  a  little  upwaxds,  so  as  not  to  be  in 
the  way  of  the  operator,  who  ties  the  lowest  suture  firmly  but 
not  too  tightly.  In  the  same  manner,  the  other  sutui-es  are 
tied,  from  below  upwards.  If  they  be  tied  too  tightly,  there 
will  be  danger  of  strangulation  of  the  tissues  when  oedema 
sets  in,  after  the  operation.  The  sutures  may  cut  through 
the  tissues  and  leave  tracks  apt  to  suppurate ;  and,  should 
the  parts  heal,  the  cicatrix  mil  be  weak  and  ill-supplied  "v^-ith 
blood-yessels.  The  sutures  must  simply  be  dra^m  firmly,  so 
that  the  edges  of  the  wound  lie  in  apposition. 

The  patient's  knees  and  thighs  are  flexed,  and  she  is  put  to 
bed,  on  her  right  or  left  side.  The  parts  must  be  left  uncovered 
by  any  T-baudage,  so  that  all  discharge  can  escape.  Small 
doses  of  opium  are  given  by  many  surgeons  during  the  first 
few  days.    Bantock  and  Tait  believe  this  di'ug  to  be  prejudicial. 

The  patient  must  continue  to  lie  on  her  side,  her  position 
being  made  comfortable  by  pillows,  until  a  day  or  two  after 
the  removal  of  the  sutures.  The  external  parts,  as  a  rule, 
requii-e  washing,  as  there  is  generally  a  little  discharge.  If 
there  be  none,  they  should  simply  be  kept  dry.  The  washing 
is  effected  by  means  of  a  stream,  of  tepid  water  from  a  syringe  ; 
the  parts  are  then  dried.  The  vagina  will  only  require  washing 
shoiild  there  be  discharge.  This  must  then  be  done  gently,  and 
care  must  be  taken  to  leave  space  for  the  retm-n-emrent,  else 
the  parts  near  the  wound  T\dll  be  stretched. 

The  catheter  must  be  used  every  six  or  eight  hours  for  several 
days,  as  a  loaded  bladder  will  make  the  patient  restless.  There 
is  probably  little,  if  any,  danger  of  urine  iiTitating  the  wound. 

The  question  of  opening  the  bowels  is  most  important. 
Dr.  Bantock  administers,  on  the  foui'th  day,  a  drachm  of  com- 
pound liquorice  powder,  or  a  grain  of  colocjTith  and  a  grain  of 
hyoscyamus,  in  the  foim  of  a  pill,  every  four  hours  until 
the  bowels  act.  If  the  bowels  be  kept  closed  for  a  week, 
scybala  ^^dll  form  and  will  put  the  united  parts  to  great 
danger,  especially  in  the  region  of  the  anus,  where  repaii*  is 
most  important.  It  is  not  advisable,  as  a  ride,  to  administer 
opium.  This  drug  certainly  appears  to  increase  the  tendency 
to  the  foi-mation  of  scj'bala,  particularly  when  the  patient  is 


PURSE- STRING    OPERATION.  399 

kept  on  a  milk  diet.  As  to  this  question  of  diet,  tlie  patient 
is  best  without  any  form  of  alcohol.  Milk  and  farinaceous 
diet  should  be  given  for  two  days  :  oatmeal  gruel  is  particu- 
larly good.  Fish  may  be  allowed  on  the  fourth  and  meat  on 
the  fifth  or  sixth. 

Removal  of  Sutures. — The  deep  perineal  sutures  should 
be  removed  between  the  eighth  and  tenth  days  after  operation. 
The  knot  of  each  suture  is  gently  drawn  down,  by  means  of 
a  pair  of  forceps,  and  the  thread  is  cut  on  one  side  of  the  knot 
with  scissors,  then  it  can  be  pulled  out.  The  rectal  sutures 
often  do  not  require  removal.  If  they  cause  pain,  they  may 
be  taken  away  in  the  same  manner  as  the  others. 

Purse-string  Operation. — There  is  an  important  modi- 
fication of  the  ordinary  operation  for  the  repair  of  a  complete 
rupture  of  the  perineum,  especially  adapted  for  cases  where 
the  sphincter  ani  and  an  inch  or  less  of  the  recto-vaginal 
wall  are  torn  through.  The  pm-se-string  operation  has  been 
advocated  by  several  distinguished  specialists,  and  I  describe 
it  as  performed  by  Dr.  Percy  Boulton.  I  am  of  opinion 
that  it  requires  more  experience  and  dexterity  than  the 
operation  which  has  just  been  detailed.  The  patient  is 
first  placed  in  the  lithotomy  position.  The  parts  having 
been  well  shaved  and  washed  with  antiseptic  lotion,  the  left 
forefinger  is  introduced  into  the  rectum.  The  operator 
then  takes  a  scalpel  in  his  right  hand  and,  cutting  from 
left  to  right,  makes  a  wound  between  the  everted  rectal 
mucous  membrane  and  the  vaginal  mucous  membrane  at 
their  line  of  union.  The  incision  must  begin  and  end  at 
the  points  marked  x  X  in  Fig.  143,  as  they  have  to  be 
brought  together  anteriorly  in  order  to  close  the  anus.  A 
tongue  of  vaginal  mucous  membrane  above  the  rent  must 
be  dissected  up  to  the  extent  of  about  thi-ee-quarters  of  an 
inch,  and  its  edges  must  be  held  up  by  pressm-e-forceps,  out 
of  the  operator's  way,  by  an  assistant.  Sometimes,  though 
rarely,  an  artery  requires  to  be  secm-ed  by  forcipressure.  The 
finger  is  now  taken  out  of  the  rectum.  The  wound  is  pro- 
longed backwards  along  the  side  of  the  anus,  and  then 
forwards,  to  about  the  extent  of  an  inch  and  a  half  alouo- 
the  junction  of   skin  and  mucous   membrane.     The  latter   is 


400  KEPAIR  OF  RUPTURED  PERINEUM. 

dissected  inwards  and  may  be  cut  off  with  scissors,  or  simply- 
turned  inwards  so  as  to  be  continuous  with  the  tongue  of 
mucous  membrane  abeady  dissected  up.  More  tissue  must 
be  removed  posteriorly  near  the  anus,  than  anteriorly.  These 
dissections  form  the  raw  sm-face  represented  in  Fig.  143.  The 
assistant  must  freely  use  the  sponges  at  this  stage. 

The  surgeon  now  begins  the  first  part  of  the  reparative 
process  by  the  introduction  of  sutm^es.  He  takes  a  shghtly 
curved  needle  about  two  inches  long,  and  threads  it  with  a  stout 
piece  of  silkworm-gut.  It  is  entered,  on  the  right  side,  at  the 
point  X ,  Fig.  143,  in  the  anal  integument,  so  as  to  pierce  the 
angle  of  the  torn  sphincter  muscle,  passed  under  the  tissues  of 
the  wound,  brought  out,  for  the  sake  of  convenience,  on  the  fi'ee 
surface  of  the  centre  of  the  wound  at  + ,  Fig.  143,  re-entered 
into  the  wound  and  passed  under  it  till  its  point  issues  at  x 
on  the  left  side  ;  the  needle  then  completely  encircles  the  tear 
through  the  recto-vesical  wall.  The  needle  is  then  withdrawn 
from  the  thread.  The  two  ends  of  the  thi-ead  will  hang  out  of 
the  integument  close  to  x  on  each  side.  The  operator  may 
keep  the  needle  entirely  under  the  surface  of  the  wound  if  he 
please,  but  this  elegant  though  difficult  manipulation  is  of  no 
advantage  to  the  patient,  and  requires  a  clumsy,  and  very 
strongly  curved  needle,  else  the  point  of  the  instrimient  is  hable 
to  break  before  it  is  brought  out  on  the  left  side.  The  suture 
(a  a,  Fig.  143)  may  now  be  tied,  if  the  operator  likes  to  see 
tangible  proofs  of  progress,  though  all  tying  may  be  left  till  the 
last  perhaps  with  advantage.  When  the  two  ends  of  the  silk- 
worm-gut are  tied,  the  points  x  X  are  brought  together  in 
front  at  -f- ;  that  is  to  say,  the  ring  of  the  anus  having  been 
torn  through  in  front  at  -f- ,  and  having  flown  asunder  so  as  to 
form  a  straight  line  with  its  torn  surfaces  at  each  extremity, 
X  X ,  is  now  restored,  these  surfaces  being  brought  once  more 
together. 

The  next  step  consists  in  restoring  the  sphincter  ani  to  its 
original  position.  The  surgeons  who  operate  after  the  method 
now  described  do  not  attempt  to  unite  the  edges  of  the  muscle 
they  merely  bring  it,  with  its  surrounding  tissues,  to  the  front, 
just  as  the  ring  of  the  anus  has  already  been  restored.  The 
silkworm-gut  is  introduced  a  little  behind  the  point  of  entry  of 


PURSE-STRING    OPERATION. 


401 


the  former  suture,  piercing  the  skin  and  torn  end  of  the  sphincter 
ani  muscle,  and  carried  upwards  under  the  surface  of  the  wound 
till  it  is  brought  out  a  little  above  + ;  that  is  to  say,  higher  in 
the  vagina  than  the  former  suture,  and  re-entered  and  once  more 
brought  out  to  the  left  opposite  the  point  of  entry  {b  h,  Fig. 
143).  The  vaginal  mucous  membrane  must  be  pulled  well  up 
at  +,  by  the  assistant,  and  a  small  piece  of  its  hinder  surface 
should  be  included  in  the  suture. 

The  third  stage   consists  in  passing  sutures  for  closing  the 


^^^^^^ 


h 

Fig.  143.— Purse-Strixg  Operatiox. 
X  X  mark  the  extremities  of  the  lacerated  anal  ring.      +  indicates  the  point 
to  which  these  extremities  are  brought  by  the  sutures,  so  as  to  restore  the  ring. 
{Boulton.)     Two  hEemorrhoids  protrude  from  the  torn  margin  of  the  rectum. 

perineum.  A  stout  handled  and  largely-curved  needle  is  passed 
under  the  surface  of  the  wound  and  the  vaginal  mucous  mem- 
brane, and  brought  out  at  the  opposite  side.  The  point  of  entry 
should  be  about  a  quarter  of  an  inch  from  the  margin  of  the 
wound  on  the  right  side.  When  the  point  of  the  needle  issues 
from  the  corresponding  point  on  the  left  side,  a  stout  silver  -^ire 
suture  is  sKpped  into  the  eye ;  the  needle  is  then  withdrawn 
(c  c,  Fig.  143).  Two  or  three  more  sutures  {d  d,  c  e,  Fig.  143) 
are  then  passed,  below  the  first,  as  indicated  in  the  diagram. 

D  D 


402  REPAIR    OF    RUPTURED    PERINEUM. 

The  highest  of  these  sutures  {r  e)  must  include  the  tongue  of 
vaginal  mucous  membrane  which  was  dissected  upwards  and 
raised  at  the  beginning  of  the  operation,  and  which  now 
will  cover  the  inner  side  of  the  line  of  incision  when  the  wire 
sutures  are  brought  together. 

The  ring  of  the  anus  has  been  restored  bj  seciu'ing  the 
threads,  a  a,  h  b  ',  or  if  they  have  not  been  tied  yet,  they  may  be 
tied  at  this  stage.  The  perineal  sutures,  c  c,  d  d,  e  e,  are  then 
drawn  forwards  and  tied  after  careful  washing  of  the  raw 
surface  as  noted  in  the  description  of  the  previous  method. 
When  these  sutures  are  tied,  the  skin  will  be  drawn  over  the 
raw  surface  and  the  tongue  of  mucous  membrane  like  the 
folding  lids  of  a  stationery-case  or  a  triptych,  and  this  duplica- 
tion makes  a  remarkably  thick  and  strong  perineum. 

It  is  most  important  that  the  gut  sutures  should  not  be  tied 
so  tightly  as  to  strangle  the  tissues  which  they  encircle  like 
purse-strings,  and  they  must  be  removed  on  the  appearance  of 
any  cutting  of  the  skin-surface  near  the  knots.  Under  any 
circumstances  they  are  usually  removed  on  the  fourth  or  fifth 
day.     The  silver  sutures  may  remain  for  a  week  or  ten  days. 

The  Operation  for  Partial  Rupture  of  the  Perineum. 
—Dr.  Graillard  Thomas  is  quite  justified  in  describing  this 
operation  as  distinct  from  that  which  has  already  been  re- 
corded. Operations  are  surgical  matters,  and  therefore  must  be 
considered  and  classified  on  surgical  principles.  The  operation 
for  rupture  including  the  sphincter  ani  is  always  difiicult  and 
uncertain.  The  restoration  of  a  ruptm^e  of  the  perineum 
which  does  not  involve  the  sphincter  is  seldom  attended  with 
much  difficulty. 

A  laceration  of  the  perineum  produced  in  the  course  of  some 
operation  where  that  part  is  exposed  to  injury,  should  be  re- 
paired at  once.  The  pressm'e  of  the  shanks  of  a  heavy  volsella 
against  the  posterior  commissure,  or  the  sudden  escape  from  the 
vagina  of  a  large  tough  fibroid  polypus  dragged  upon  by  that 
instrument,  may  cause  a  laceration  of  this  kind. 

Partial  lacerations  caused  by  injuries  received  during  labour 
are  occasionally  so  trifling  as  to  produce  no  symptoms,  nor 
must  the  surgeon  conclude  that  any  symptom  of  which  a 
patient  may  complain  must  be  due  to  a  partial  laceration  which 


PARTIAL    RUPTURE.  403 

he  discovers  on  examination.  Nevertheless,  troublesome  results 
not  rarely  follow  this  condition,  and  when  the  perineum  is  torn 
through  apparently  almost  as  far  as  the  sphincter  ani,  and  the 
posterior  vaginal  wall  shows  a  distinct  tendency  to  prolapse,  the 
surgeon  is  perfectly  justified  in  proposing  an  operation  even 
though  there  be  no  loss  of  power  over  the  sphincter. 

In  partial  rupture  the  tissues  of  the  perineum  simply  gape.* 
The  structm-es  along  the  middle  line  are  torn  through  at  the 
extremity  of  the  vulva,  the  laceration  extending  backwards 
along  the  raphe,  and  ceasing  at  a  point  in  front  of  the  anus. 
Hence,  the  edges  of  the  laceration  lie  widely  apart  anteriorly, 
and  meet  posteriorly  at  the  point  where  the  laceration  ceased  ; 
in  other  words,  they  form  a  Y  with  its  point  backwards.  The 
solid  tissue  of  the  perineal  body  is  also  deeply  torn  through  in 
front.  Passing  backwards,  the  rent  becomes  shallower  and 
shallower,  ceasing  at  the  point  of  the  V,  and  each  half  of  the 
deep  tissues  torn  through  lies  on  one  side-  of  the  middle  line. 
I  have  seen  a  fresh  laceration,  after  an  operation  for  the  extrac- 
tion of  a  fibroid  polypus,  and  it  presented  all  these  characters. 
In  fact,  it  was  precisely  the  kind  of  raw  surface  which  the 
surgeon  denudes  when  the  operation  is  performed  after  the 
exposed  surfaces  have  cicatrized,  as  shown  at  Fig.  141,  where, 
however,  the  rectum  has  been  involved. 

If  the  laceration  be  not  repaired  at  once,  the  raw  sm'faces 
tend  to  come  gradually  down  to  the  same  plane  as  that  of  the 
margins  of  the  laceration,  as  in  complete  ruptm-e,  in  the 
manner  already  described  at  page  1390.  It  is  evident,  however, 
that  this  can  only  occur  to  any  appreciable  extent  in  front. 
Still,  whatever  part  the  perineum  may  or  may  not  play  in 
supporting  the  pelvic  structures,  the  pelvic  floor  must  be 
materially  affected  by  this  descent  of  the  lacerated  tissues. 

Cicatrization  tends  to  alter  relations  yet  further,  the  lacera- 
tion being  at  length  reduced  to  a  V-shaped  line  of  scar-tissue, 
forming  the  anterior  boundary  of  the  remains  of  the  perineum. 
The  vaginal  mucous  membrane  often  bulges  downwards  con- 
spicuously along  this  line. 

*  I  must  refer  to  the  works  of  Matthews  Duncau,  Emmet,  and  Thomas,  passhn, 
for  scientific  opinions  as  to  how  much  of  the  laceration  involves  vaginal  and 
perineal  tissues  respectively. 


404  REPAIK  OF  RUPTURED  PERINEUM. 

Principles  of  the  Operation. — "WTien  the  laceration  is  recent, 
all  that  is  necessary  is  to  pass  sutures  above  the  raw  surface, 
emerging  through  the  integuments  external  to  its  borders.  On 
di'a"v\*ing  the  sutiu'es  together,  the  Y-shaped  gaping  margins 
will  be  closed  and  the  two  halves  of  the  lacerated  sui'face  will 
be  in  apposition.  When  the  parts  have  cicatrized,  a  Y-shaped 
surface  must  first  be  dissected  up. 

Step)s  of  the  Operation. — When  the  laceration  is  produced 
during  an  operation,  as  above  noted,  it  should  be  sewn  up  at 
once,  unless  the  surgeon  has  reason  to  believe  that  particular 
cii'cumstances,  such  as  the  proximity  of  inflammatory  changes, 
discharges,  etc.,  might  interfere  with  union.  The  manner  of 
applying  the  sutures  "v^-ill  be  described. 

Before  a  defeiTed  operation,  the  patient  should  be  prepared 
as  for  the  more  severe  procedure  when  the  sphincter  ani  is 
involved.  She  is  placed  in  the  lithotomy  position.  A  Y-shaped 
incision  is  made  through  the  integuments,  by  means  of  a 
scalpel.  Each  half  of  this  incision  should  begin  at  the  ex- 
tremity of  the  labium  ma  jus,  and  end  posteriorly  by  joining 
its  fellow  in  the  middle  line,  in  front  of  the  untorn  remains  of 
the  perineum.  Then  an  incision,  curved  backwards,  is  made 
across  the  vaginal  mucous  membrane,  between  the  anterior 
extremities  of  the  Y-shaped  line.  The  mucous  membrane  and 
cicatricial  tissue  lying  "within  the  limits  of  the  incision  are  now 
dissected  up  so  that  a  -^-ide  raw  surface  is  formed  (as  in  Fig. 
141).  The  surgeon  must  not  make  his  incisions  too  short  or 
the  area  of  raw  sui^face  too  narrow,  as  his  aim  is  to  form  a 
deep  and  strong  perineum. 

The  sutures  are  now  applied  (Fig.  141),  omitting  the  anal 
sutures  which  will  not  be  needed,  as  in  the  operation  for 
complete  laceration,  and  are  closed  with  the  same  precautions. 

The  after-treatment  will  be  the  same  as  after  that  oj)eration. 
There  ■«dll  be  httle  fear  of  damage  when  the  bowels  are  opened, 
but  the  parts  should  be  kept  at  rest  for  three  or  four  days ;  then 
an  aperient  should  be  given,  and  the  sutures  may  be  removed 
at  the  end  of  a  week. 

Plastic  and  other  Operations  for  the  Relief  of 
Prolapse  of  the  Uterus  or  Vaginal  Walls. — In  this 
Handbook  the  pathology  of  uterine    displacements  cannot  be 


PERIXEORRHAPHY    FOR    PROLAPSUS-  40c> 

discussed.  The  extreme  forms  of  prolapse  of  the  yaginal  walls, 
with  or  without  descent  of  the  uterus,  are  familiar  to  everj 
practitioner.  Several  operative  measures  have  been  devised' for 
theii'  relief,  in  cases  where  pessaries  can  no  longer  be  worn, 
or  fail  to  give  support.  All  these  operations  demand  con- 
siderable experience  in  the  treatment  of  diseases  of  women,  and 
even  when  they  are  performed  hj  experts,  the  results  are  not 
on  the  whole  satisfactory.  I  shall  briefly  describe  these  opera- 
tions, which  may  be  gi-ouped  as  follows  : — 1.  Plastic  operations 
on  the  perineum  and  adjacent  structures.  2.  Plastic  operations 
on  the  vagina.  3.  Operations  performed  on  the  round  liga- 
ments. Hysterorrhaphy,  where  the  fundus  uteri  is  sewn  to  the 
parietal  peritoneum,  is  an  operation  which  is  not  likely  to 
commend  itself  to  the  general  surgeon.  It  has,  however,  found 
advocates  among  experienced  speciaKsts. 

Plastic  Operations  on  the  Perineum  in  Prolapsus — 
Perineorrhaphy. — When  partial  rupture  of  the  perineum 
exists  in  a  case  of  prolapse  of  the  pelvic  viscera,  the  latter  con- 
dition is  decidedly  aggravated,*  nor  is  it  always  possible  for 
the  patient  to  wear  a  pessary.  The  distension  of  the  perineum 
in  an  old  case  of  procidentia,  or  complete  prolapse  of  the  uterus, 
causes  it  to  become  atrophied,  thinned,  and  stretched  out,  so 
that  the  descending  viscera  push  it  backwards  and  readily  slip 
do^\Ti  thi'oug-h  the  enlarg'ed  vulvar  orifice.  In  cases  of  this  kind 
no  pessary  can  possibly  be  retained.  Hence  the  repair  of  a 
partial  rupture  is  often  undertaken  for  the  relief  of  prolapse. 
When  the  perinemn  is  stretched,  without  previous  traimiatic 
injmy,  its  anterior  part  is  sometimes  vivified,  so  that  a  raw 
surface  is  made,  in  f onn  more  or  less  like  that  which  is  dissected 
up  in  the  operation  for  ruptured  perineum.  This  sm-face  is 
then  united  by  sutm-es.  The  raw  surface  is  sometimes  pro- 
longed at  each  extremity  so  as  to  involve  the  posterior  part  of 
the  labia  majora  (episiorrhaphy).  When  the  sm-face  is  closed, 
in  this  operation,  the  vulvar  orifice  will  be  much  diminished  in 
circumference.  The  patient  must  rest  as  long  after  any  of  the 
above  operations  as  when  a  traumatic  ruptui'e  of  the  perineum 
has  been  repaired.  The  heavy  uterus  ^ill  become  smaller  and 
lighter  after  this  prolonged  repose. 

*  Set;  Matthews  Duiicau,  Papers  on  the  Female  Perineum,  1879,  p.  137. 


406  RELIEF  OF  PROLAPSUS  UTERI. 

None  of  these  proceedings  afford  a  permanent  ciu'e.  The 
j)atient  feels  great  comfort  from  rest  after  the  operation,  and 
can  wear  a  ring  or  a  Zwank's  pessary.  The  hulky  uterus,  how- 
ever, ultimately  forces  its  way  once  more  beyond  the  vulva. 

Plastic  Operations  on  the  Vagina  in  Prolapse. — 
The  narrowing  of  the  calibre  of  the  vagina  by  operation  is  a  far 
more  effectual  proceeding  for  the  relief  of  prolapse.  When 
part  of  the  perineum  and  posterior  part  of  the  labia  majora  are 
made  raw,  the  dissection  may  be  continued  half  an  inch  or 
an  inch  up  the  posterior  vaginal  wall,  or  even  close  up  to 
the  cervix.  The  edges  of  the  dissected  surface  are  afterwards 
brought  together  by  sutures,  which  are  passed  behind  them,  as 
in  the  operation  for  repair  of  partial  rupture  of  the  perineum 
(page  396,  and  Fig.  141).  The  edges  of  the  greater  part  of 
the  vaginal  woimd  Avill  requii'e  union  by  superficial  sutures 
(Fig.  142).  This  operation  is  known  as  clyivoperineovyhaphn. 
Specialists  differ  very  much  in  certain  details,  especially  as 
regards  the  form  of  the  area  of  the  vaginal  mucous  membrane 
which  is  vivified.  Some  dissect  away  a  wedge-shaped  piece, 
with  its  point  upwards  and  its  base  continuous  with  the  raw 
sui'face  in  the  perineal  region.  This  is,  perhaps,  the  simplest 
kind  of  dissection.  Others  make  two  triangles  of  raw  surface 
on  the  vaginal  wall,  the  apices  pointing  upwards,  the  bases 
meeting  the  raw  perineal  sui"face  and  joining  each  other  in 
the  middle  line.  The  edges  of  each  triangle  are  sewn  up. 
When  both  have  been  treated  in  this  manner,  the  calibre  of 
the  vagina  will  be  greatly  diminished. 

Elytrorrhaphy  or  Colporrhaphy. — These  formidable 
terms  are  given  to  some  ingenious  operations  for  the  direct 
diminution  of  the  calibre  of  the  vagina,  as  a  remedy  in 
cases  of  prolapse  of  the  pelvic  viscera. 

Any  condition  which  makes  the  vagina  narrower  will  act,  to 
a  certain  extent  and  for  a  certain  period,  beneficially  on  uterine 
and  vaginal  prolapses.  Even  cicatrization  after  the  use  of 
caustics  has  proved  sufficient  for  a  time.  It  is  clearl}^  more 
surgical  to  employ  the  knife,  and  to  diminish  the  redun- 
dant walls  of  the  vagina  by  dissecting  off  pieces  of  the 
mucous  membrane  and  sewing  together  the  edges.  Different 
operators   have   devised   many   methods   of  dissecting   up  the 


SlMS'    ELYTRORRHAPHY.  407 

mucous  membrane.  Perhaps  it  is  more  correct  to  say  that  they 
have  designed  a  large  series  of  patterns  of  the  area  to  be  vivified. 
A  study  of  these  details  is  apt  to  confuse  the  beginner,  but  Dr. 
Gaillard  Thomas's  assertion,  that  "  any  figure  which  results  in 
constriction  of  the  vaginal  wall  will  remove  traction  from 
the  uterus  and  keep  the  vagina  from  prolapsing,"  includes  a 
truth  that  will,  for  a  time,  greatly  simplify  the  problem.  Thus 
Dieffenbach's  oval  denudation  is  the  easiest  for  the  inexperi- 
enced. Sims'  and  Emmet's  methods  are  well  known,  so  that 
these  different  plans  of  denuding  the  vaginal  mucous  mem- 
brane will  be  described. 

Sims'  Elytrorrhaphy  or  Colporrhaphy. — This  is  one  of 
the  most  recognized  of  the  ingenious  operations  devised  by  Dr. 
Marion  Sims.  It  is,  however,  more  familiar  to  us  in  the  pages 
of  text-books  than  in  the  operating  theatre ;  indeed,  it  is  not 
often  performed. 

Sims,  Graillard  Thomas,  Schroder,  and  others  insist  that  this 
and  all  other  forms  of  elytrorrhaphy  are  primarily  intended  to 
remedy  the  vaginal  prolapse,  and  so  to  prevent  the  descending 
vaginal  walls  from  dragging  the  uterus  after  them.  Hence, 
according  to  these  views,  the  operation  necessary  for  prolapse 
of  the  uterus  will  be  the  same  as  that  which  is  needed  for 
prolapse  of  the  vaginal  wall.  Elytrorrhaphy  cannot  support 
the  uterus  by  narrowing  the  calibre  of  the  vagina,  for  no 
vagina,  narrow  or  wide,  is  a  uterine  support. 

The  transitory  character  of  the  benefits  derived  from  elytror- 
rhaphy is,  on  the  other  hand,  due  to  the  deep-seated  nature  of 
the  cause  of  prolapse  of  the  vagina.  This  condition  is  very 
often  a  form  of  hernia,  represented  amongst  the  patient's 
relatives  by  inguinal,  femoral,  and  umbilical  hernite.*  Thus, 
after  operation,  the  pressure  of  the  abdominal  viscera  contimies 
to  bear,  as  it  did  before,  to  an  abnormal  extent  in  the  direction 
of  the  pelvic  outlet.  Hence,  the  cicatrices  ultimately  stretch, 
and  the  descent  of  the  vaginal  wall  occm-s  once  more.  In  so 
far  that  a  prolapse  of  the  anterior  vaginal  wall  is  cured  for  a 
time,  elytrorrhaphy  performed  upon  tliat  wall  is  at  least  logical. 

*  I  recorded  three  strong  family  histories  of  this  kind  in  a  paper  entitled  "  The 
Relation  of  Prolapse  of  the  Vagina  to  Hernia "  ( Transactions  of  the  Obstetrical 

Society  of  London,  vol.  xxvi.  1884,  p.  88). 


408  RELIEF    OF    PROLAPSUS    UTERI. 

The  pressure  of  the  bladder,  however,  tends  to  stretch  the 
cicatrix  from  the  fii'st,  as  practice  can  abundantly  prove. 

In  Sims'  operation,  the  patient  is  placed  on  her  left  side,  and 
the  posterior  wall  of  the  vagina  is  retracted  by  the  larger  blade 
of  a  Sims'  speculum.  A  special  cmwed  sound  with  forked 
points  is  then  passed  straight  along  the  middle  line  of  the 
anterior  vaginal  wall  till  the  points  are  fixed  in  the  anterior 
aspect  of  the  cervix.  Then  an  assistant  takes  hold  of  the  handle 
of  the  sound  and  keeps  the  shank  of  that  instrument  evenly  and 
firmly  pressed  against  the  middle  line  of  the  anterior  wall.  As 
that  wall  is  very  lax  under  the  conditions  where  elytrorrhaphy 
is  performed,  a  deep  depression  is  formed,  hiding  the  sound. 

The  operator,  by  pressing  together  the  folds  of  vaginal 
mucous  membrane  on  each  side  of  the  depression,  can  estimate 
how  far  the  vagina  must  be  narrowed.  Then  he  catches  up  the 
mucous  membrane  half  an  inch  above  and  on  one  side  of  the 
meatus  urinarius,  with  tenaculum  or  spring-forceps,  and  cuts 
away  a  thin  strip  of  mucous  membrane  extending  upwards  and 
outwards  to  one  side  of  the  cervix.  Another  strip  is  then  cut 
on  the  opposite  side,  beginning  at  the  same  point  above  the 
meatus.  Thus  a  Y-shaped  area  of  denudation,  about  a  quarter 
of  an  inch  wide,  is  formed  on  the  anterior  vaginal  wall,  with 
the  point  just  above  the  meatus,  and  the  end  of  the  arm  below 
and  external  to  the  cervix.  The  special  sound  is  then  removed. 
The  cervix  is  pulled  down  by  a  volsella,  and  a  strip  of  mucous 
membrane  is  cut  away  transversely  from  the  inner  side  of  each 
upper  extremity  of  the  V.  These  transverse  denudations  run 
beneath  the  front  of  the  cervix  and  nearly  meet  each  other. 
The  assistant  must  make  free  use  of  stick-sponges  to  restrain  the 
hoemorrhage. 

A  silver  wire  or  silkworm-gut  sutiu-e  is  then  passed  under  the 
point  of  the  V,  entering  and  emerging  about  an  eighth  of  an  inch 
from  the  margin  of  the  raw  surface.  Sutiu'es  are  then  passed 
in  the  same  manner  under  the  surfaces  all  the  way  up,  running 
fi-ee  across  the  sui^face  of  mucous  membrane  left  between  the 
arms  of  the  V.  The  highest  sutures  must  pass  under  the  trans- 
verse denudations  on  the  inner  sides  of  the  upper  extremities  of 
the  arms  of  the  V.  The  sutures  are  lastly  tied.  Then  the  two 
arms  of  the  Y  and  the  transverse  pieces  are  brought  into  appo- 


ELTTRORRHAPHY SIMS'    AND    EMMEt's    MEIHOUS.  409 

sition.  Thus  the  vagina  is,  as  it  were,  buttoned  up  tightly  in 
front  from  the  vulva  to  close  below  the  cervix. 

The  patient  must  lie  in  bed  for  over  a  fortnight,  and  the 
bladder  must  never  be  allowed  to  become  distended,  else  the 
cicatrix  will  be  stretched  or  broken  down.  The  lower  sutures 
may  be  removed  on  the  tenth,  the  upper  on  the  fifteenth  day. 
The  patient  must  avoid  prolonged  or  violent  exercise  for  many 
months. 

This  operation  may  certainly  give  relief  for  several  years. 
In  one  case,  however,  where  Dr.  Marion  Sims  operated,  the 
patient,  after  living  in  comfort  for  fom-  years,  was  suddenly 
seized  with  severe  pain  following  a  muscular  effort.  Constant 
tenesmus  and  great  suffering  persisted  for  three  months.  Dr. 
Emmet  then  saw  the  jDatient,  and  found  that  the  cervix  had 
slipped  into  the  pouch  behind  the  septum  formed  by  the 
operation  ;  the  fundus  lay  in  the  hollow  of  the  sacrum.  The 
incarcerated  cervix  was  disengaged,  and  the  uterus  returned 
to  its  normal  position,  to  the  great  relief  of  the  patient.  Owing 
to  the  possibility  of  this  accident,  and  the  tendency  of  the 
anterior  vaginal  wall  to  descend  again.  Dr.  Emmet  devised 
an  operation  which  he  believes  to  be  superior  to  that  which 
has  just  been  described. 

Emmet's  Elytrorrhaphy  or  Colporrhaphy  for  Pro- 
lapse and  Procidentia. — The  steps  of  this  operation,  like 
those  of  the  former,  have  frequently  been  described  in  text- 
books. Most  authors  have  condensed  Dr.  Emmet's  original 
account ;  I  think  it  preferable  to  reproduce  that  account  in  full. 
{The  Principles  and  Practice  of  Gz/mecologi/,  Thivd  Edition,  1885.) 

"  I  first  ante  vert  the  uterus  with  my  finger,  as  the  patient  lies 
on  the  back.  The  neck  of  the  uterus  is  then  kept  crowded  up 
into  the  posterior  cul-de-sac  by  a  sponge-probang  in  the  hands 
of  an  assistant,  while  the  patient  is  being  placed  on  the  left 
side  for  the  introduction  of  the  speculum.  I  then  endeavom-  to 
find  two  points,  one  about  half-an-inch  from  the  cervix  on  each 
side,  and  a  little  behind  the  line  of  its  anterior  lip,  which  can  be 
drawn  together  in  front  of  the  uterus  by  means  of  a  tenaculum 
in  each  hand.  When  two  such  points  can  be  thus  brought 
together  without  undue  tension,  forming  triangular-shaped  folds, 
the  sm^faces  are  to  be  freshened.     One  of  the  tenacula  must  be 


410 


RELIEF  OF  PROLAPSUS  UTERI. 


securely  hooked  in  the  tissues,  to  indicate  the  point.  Then,  one 
hand  being  disengaged,  a  surface  about  half  an  inch  square 
around  the  point  of  the  other  tenaculum  is  to  be  denuded  with 


Fig.  144. — Emmet's  Elytkorehaphy. 

Diagram  representing  the  wire  passed  under  the  three  freshened  surfaces  on  the 
mucous  membrane  of  the  anterior  vaginal  wall,  below  the  os  uteri. 

a  pair  of  scissors.  Next  a  similar  surface  is  to  be  freshened 
around  the  point  of  the  first  tenaculum,  and  a  strip  afterwards 
removed  from  the  vaginal  surface,  in  front  of  the  uterus,  about 


Fig.  145. — Emmet's  Elytuorehaphy. 

The  raw  surfaces  are  united  close  to  the  cervix.     The  two  folds  in  the  anterior 
vaginal  wall  are  vivified,  and  two  sutures  already  introduced.     See  text. 


an  inch  long  by  half  an  inch  wide.  Having  passed  a  needle, 
armed  with  a  silk  loop,  beneath  each  of  these  freshened  sui'faces, 
as  shown  in  Fig.  144,  a  silver  wire  is  to  be  attached  to  the  loop 


emmet's   EL'XTRORRHAPHY.  411 

and  secured,  by  twisting,  thus  bringing  together  in  front  of  the 
cervix,  as  will  be  seen  in  Fig.  145,  these  three  points. 

"  The  completion  of  the  operation,  after  the  cervix  is  thus 
fixed  in  position,  is  very  simple.  Fig.  145  shows  the  two  folds 
on' the  anterior  wall,  in  the  shape  of  an  ellipse,  extending  from 
the  surfaces  secured  in  front  of  the  uterus  nearlj^  to  the  vaginal 
outlet.  These  are  to  be  turned  in  by  finding,  with  tenacula, 
from  time  to  time,  opposite  points  near  the  crest  of  each  fold, 
which  can  be  brought  together  without  tension.  With  the 
object  of  preventing  any  unnecessary  loss  of  blood,  only  half 
an  inch  on  each  side  need  be  denuded  at  a  time,  one  or  more 
sutures  being  introduced  and  secured.  Thus  advancing  step  by 
step,  the  operation  is  completed  by  turning  in  these  folds  until 
at  length  they  become  lost  on  the  vaginal  surface  near  the  neck 
of  the  bladder.  Four  or  five  sutures  should  be  inserted  to  the 
inch,  passing  first  a  silk  loop  to  which  the  silver  sutiu"e  is  to  be 
attached  for  the  purpose  of  drawing  it  through.  The  needle 
should  be  introduced  so  as  to  include  a  liberal  amount  of  tissue, 
and  the  sutures  twisted  only  just  sufficiently  to  bring  the  raw 
sm^faces  in  contact,  that  strangulation  from  the  swelling  of  the 
parts  may  be  avoided.  The  sutures  are  usually  removed  on  the 
eighth  to  the  tenth  day.  No  special  after-treatment  is  needed, 
beyond  keeping  a  self-retaining  sigmoid  catheter  in  the  bladder 
until  the  parts  have  become  well  united.  When  from  any  cause 
the  catheter  cannot  be  retained,  the  bladder  should  be  emptied 
every  few  hours,  so  that  the  weight  of  a  quantity  of  urine  may 
not  be  borne  by  the  recently  united  surfaces.  If  it  be  necessary 
to  empty  the  bladder  on  a  bed-pan,  a  little  tepid  water  should 
be  thrown  into  the  vagina  immediately  afterwards,  for  fear  that 
some  urine  may  have  passed  in ;  by  this  method  its  effects  on 
the  uniting  surfaces  would  be  neutralized.  It  is  absolutely 
necessary  to  confine  the  patient  to  the  recumbent  position  for 
two  or  three  weeks." 

Dr.  Emmet  sometimes  performs  a  modification  of  this  opera- 
tion when  the  upper  portion  of  the  vagina  has  become  dilated 
by  an  enlarged  uterus  resting  on  the  floor  of  the  pelvis.  The 
folding  in  of  the  anterior  vaginal  wall,  and  the  vivifying  and 
suturing  of  the  apposed  surfaces  need  only  be  extended  for  a 
short  distance  downwards,  so  that  but  two  or  thi-ee  sutures  wiU 


412  RELIEF    OF    PROLAPSUS    UTERI. 

be  needed.  He  prefers  this  operation  to  temporary  relief  by  a 
pessary. 

Other  Modifications  of  Ely tr or rhaphy.— Neither  Sims' 
nor  Emmet's  method  just  described,  is  often  performed  in 
this  country.  The  soundness  of  the  principle  of  operating 
on  the  anterior  wall  is  much  questioned.  Lefort  devised  an 
operation  for  uniting  the  anterior  and  posterior  vaginal  walls. 
The  prolaj)sed  uterus  is  kept  down,  and  two  raw  sm-faces,  each 
about  two  and  a  half  inches  long  and  three-quarters  of  an  inch 
broad,  are  formed  by  dissecting  the  mucous  membrane  off  the 
anterior  wall  of  the  vagina  by  means  of  forceps  and  scissors. 
The  uterus  is  then  drawn  forwards  and  two  similar  strips  are 
dissected  off  the  posterior  vaginal  wall.  The  uterus  is  then 
partially  reduced,  till  the  uppermost  parts  of  the  four  raw 
surfaces  are  in  apposition ;  these  sm-faces  are  united  by  car- 
bolized  catgut  sutures  passed  through  their  apposed  edges. 
This  must  be  done  on  both  sides  of  each  surface.  If  silk  or 
silkworm-gut  be  used,  the  removal  of  the  sutui'es  will  be  neces- 
sary, and  this  will  be  difficult.  Then  the  uterus  is  pushed  up 
a  Kttle  higher  and  the  raw  siu'faces  are  sutui-ed  again,  as  before. 
The  process  is  repeated  until  the  lower  extremities  of  the  sur- 
faces have  been  sutm-ed.  Neugebauer  dissects  up  a  raw  sm-face, 
about  an  inch  and  a  half  long  and  half  an  inch  wide,  on  the 
anterior  and  posterior  vaginal  walls,  and  unites  them  by  suture. 

Thomas,  Simon,  and  others  advocate,  more  or  less  strongly, 
posterior  elytrorrhaphy.  A  simple  oval  tract  of  mucous  mem- 
brane, reaching  from  the  cervix  to  the  posterior  extremity  of 
the  vulvar  orifice,  and  wide  or  narrow  according  to  the  greater 
or  less  redimdancy  of  the  tissues,  may  be  dissected  up  from  the 
posterior  wall  of  the  vagina,  the  patient  having  been  placed  in 
the  lithotomy  position.  Then  silkworm-gut  sutm-es  are  passed 
thi'ough  the  mucous  membrane  close  to  the  edge  of  the  raw 
surface,  then  transversely  under  the  surface,  emerging  through 
the  mucous  membrane  on  the  opposite  side.  The  sutures  are 
lastly  tied  ;  the  posterior  wall  will  then  be  greatly  diminished  in 
dimensions.  The  after-treatment  will  be  the  same  as  in  cases 
where  a  ruptm'e  of  the  perineum  has  been  repaired. 

Operations  for  the  Relief  of  Prolapse,  &c.,  per- 
formed from  the  Abdominal  Side  of  the  Uterus. — 


HYSTERORRHAPHY ALEXANDER'S    OPERATION.  413 

Caneva  proposed  to  unite  the  fundus  uteri  to  the  peritoneum, 
on  the  anterior  part  of  the  abdominal  walls,  by  sutures, 
without  opening  the  abdominal  cavity.  Several  specialists 
have  stitched  the  uterus  to  the  abdominal  walls  after  removal 
of  the  appendages,  and  advocate  this  step  whenever  the 
uterus  has  been  long  prolapsed  or  retroflexed,  and  is  unable 
to  stand  alone  when  elevated.  This  operation,  which  has  been 
termed  "  hysterorrhaphy,"  is  based  on  disputed  theories,  and  is 
not  likely  to  become  universally  established.* 

There  is  another  operation  which  has  been  frequently  per- 
formed, and  has  met  with  many  advocates.  It  consists  in 
exposing  the  round  ligaments  in  the  inguinal  canal,  and  shorten- 
ing them  so  as  to  draw  up  the  uterus  and  vagina.  This  operation 
is  generally  known  by  the  name  of  Dr.  Alexander,  of  Liver- 
pool ;  but  Freund,  Ai^an,  Rivington,  and  Adams,  of  Glasgow, 
have  all  had  a  share  in  its  introduction.  It  has  been  performed 
for  retroflexion,  retroversion,  prolapse,  and  allied  displacements. 
The  operation  is  difficult  and  by  no  means  unattended  by 
danger.  I  have  known  of  cases  where  it  has  proved  fatal.  As 
the  maladies  for  the  relief  of  which  it  is  undertaken  are  not 
dangerous  to  life,  the  justifiability  of  this  proceeding  is  cjues- 
tionable.  Many  specialists,  however,  practise  it,  and  I  there- 
fore shall  not  pass  it  over.  I  agree  with  Drs.  Hart  and 
Barbour  that  "  sufficient  is  not  yet  known  about  the  residts  of 
this  operation."  It  must  be  admitted  that  Dr.  Alexander  has 
detailed  his  experience  in  an  explicit  and  conscientious  manner. 
He  insists  that  any  surgeon  who  j)roposes  to  operate,  however 
experienced  in  surgery  and  learned  in  practical  anatomy,  should 
first  perform  the  steps  of  the  operation  a  few  times  on  the  dead 
subject.  He  also  admits  that  the  operation  was  orginally 
devised  to  get  rid  of  the  swarm  of  patients  with  uterine  dis- 
placements that  infested  the  gynsecological  wards  at  Liverpool 
Workhouse. 

Shortening  of  the  Round  Ligaments,  or  Alexander's 
Operation. — I  shall  now  describe  the  operation  according  to 
the  directions  given  by  Dr.  Alexander  himself  t  : — 

*  See  Dr.  Howard  Kelly,  American  Journal  of  Obstetrics,  January,  1887. 
t  The  Treatment  of  Backward  Displacements  of  the  Uteriis,  and  of  Prolapsus 
Uteri,   by  the  New   Method  of  Shortening  the  Round  Ligaments,  188-1.      "The 


414  RELIEF  OF  PROLAPSUS  UTERI. 

After  tlie  patient  has  been  narcotized,  the  pubes  is  shaved  on 
each  side  from  the  spine  outwards.  An  incision  about  two 
inches  in  length  is  made  along  the  course  of  the  inguinal 
canal,  beginning  from  the  spine  of  the  pubes.  This  incision 
must  be  free ;  if  under  two  inches,  the  subsequent  and  more 
important  manipulations  of  deeper  structures  cannot  be  safely 
accomplished.  The  subcutaneous  fat  is  sometimes  thick,  and 
the  layer  of  superficial  fascia  may,  in  such  cases,  be  mistaken 
for  the  aponeurosis  of  the  external  oblique ;  it  lies  in  the  fat 
midway  between  that  aponem'osis  and  the  skin.  Bleeding 
vessels  must  be  secured  by  means  of  pressure-forceps.  When 
the  pearly  glistening  tendon  of  the  external  oblique  muscle  has 
been  exposed,  the  external  abdominal  ring  must  be  found. 
The  inter- columnar  bands,  obHque  fibres  in  the  aponeurosis 
immediately  above  the  ring,  will  aid  the  operator  in  his  search. 
When  the  subject  is  fat,  retractors  will  be  necessary.  The 
orifice  of  the  ring  is  occupied  by  a  little  mass  of  connective 
and  adipose  tissue.  The  pubic  spine  and  the  ring  will  be 
discovered  by  the  introduction  of  the  forefinger  into  the  wound. 

The  inter-columnar  bands  are  then  cut  across,  in  the  direction 
of  the  inguinal  canal.  A  fleshy  rounded  structure  of  a  dull 
red  coloiu'  now  bulges  out  ;  it  is  mixed  with,  and  often  concealed 
by  fat.  Dr.  Alexander  states  that  he  has  never  met  with  any 
difficulty  in  recognizing  it ;  but  some  good  operators  have 
informed  me  that  this  is  not  in  accordance  T^dth  their  owti 
experience  of  the  operation.  This  fleshy  structure  is  the  end  of 
the  histologically  ligamentous  part  of  the  round  ligament, 
immediately  above  its  termination  in  the  tissues  of  the  mons 
veneris.  Close  along  its  anterior  surface  runs  the  genital 
branch  of  the  genito-crural  nerve.  If  there  be  any  difficulty 
in  recognizing  the  ligament,  the  inguinal  canal  may  be  opened 
up  for  half  an  inch.  Fasciculi  of  the  internal  obKque  may  be 
taken  for  the  round  ligament.  An  anemysm  needle  is  then 
passed  under  the  whole  of  this  tissue,  so  as  to  raise  it  out  of 
its  bed  in  the  inguinal  canal,  when  it  may  be  grasped  by  the 
fingers.  The  operator  must  make  sure  that  the  whole  of  the 
tissue  of  the  ligament  is  raised  by  the  aneurysm  needle,  and 

Operation  of  Correcting  some  Uterine  Displacements  by  Shortening  the  Round 
Ligaments"  [British  Gyncecological  Journal,  vol.  i.,  p.  246). 


Alexander's  operation.  415 

forceps,  if  employed  at  all,  should  be  blunt-pointed,  and  must 
be  used  with  caution,  for  it  is  essential  that  the  ligament  be 
grasped  entire  and  protected  from  splitting  or  tearing. 

The  end  of  the  round  ligament  is  now  gently  pulled  out  by 
the  fingers  or  by  broad  blunt-pointed  forceps,  and  separated  by 
scissors  from  the  bands  of  connective  tissue  which  bind  it  to 
adjacent  structures.  Its  nerve  will  require  division  during  this 
process,  and  there  is  some  risk  of  the  ligament  itself  being  torn 
asunder.  "When  the  adhesions  are  separated,  the  ligament 
comes  well  into  sight ;  it  appears  as  a  strong  white  cord 
which  can  be  drawn  out  with  ease.  The  operator  must  not 
forget  that  the  ligament,  which  runs  outwards  and  shghtly 
upwards  in  the  inguinal  canal,  changes  its  course  abruptly  at 
the  internal  ring,  turning  downwards,  backwards,  and  inwards 
towards  the  uterus.  Hence  when  it  is  held  up,  at  the  external 
ring,  and  pidled,  it  is  subjected  to  a  considerable  strain  at  the 
point  where  it  bends  sharply  as  it  enters  the  canal.  Indeed,  at 
this  point  it  has  become  torn  in  more  than  one  case.  On  the 
other  hand.  Dr.  Alexander  declares  that,  when  properly  set  free, 
the  round  ligament  comes  out  so  easily  that  an  inexj^erienced 
operator  may  think  that  it  has  been  ruptured. 

The  structures  already  exposed  are  now  covered  with  a  sponge, 
and  the  above-described  stages  of  the  operation  are  repeated  on 
the  opposite  side.  The  operator  should  change  sides  with  his 
assistant,  always  standing  opposite  to  the  side  on  which  he 
operates.  Both  the  round  ligaments  being  liberated,  a  second 
assistant  passes  a  sound  into  the  uterus  and  holds  the  organ  in 
its  natural  position  by  the  aid  of  that  instrument,  keeping  his 
finger  against  the  cervix.  The  ligaments  are  then  drawn  evenly 
and  gently  by  the  operator  until  the  sound  is  slightly  moved.* 

*  ' '  How  far  are  the  ligaments  to  be  pulled  out  ?  Sly  reply  is,  to  put  the 
uterus  in  position  and  pull  out  the  slack.  After  the  ligaments  have  been  freed 
they  come  out  readily  for  a  certain  distance,  and  then  decided  resistance  is  felt, 
accompanied  by  movement  of  the  replaced  uterus.  Any  further  traction  pulls  up 
the  broad  ligaments  and  the  uterus,  and  finally  is  met  by  the  resistance  of  the 
opposite  ligament  till  the  uterus  is  elevated  to  the  abdominal  wall.  Now  this 
lifting  of  the  uterus  is  an  unnatural  procedure.  That  organ  never  hangs  sus 
pended  under  any  normal  conditions,  and  to  suspend  it  by  the  ligaments  must 
lead  to  failure.  All  we  can  do  is  to  replace  the  uterus  in  its  normal  position, 
and  this  occurs  generally  when  the  decided  check  upon  the  pulling  out  of  the 
ligaments  takes  place." — Dr.  Alexander,  loc.  cit. 


416  RELIEF    OF    PROLAPSUS    TITERL 

The  first  assistant  now  holds  the  ligaments  in  place,  whilst 
the  operator  fixes  them.  This  is  done  by  stitching  each  liga- 
ment to  both  pillars  of  the  ring  by  two  moderately  fine  catgut 
sutures  on  each  side,  introduced  by  means  of  a  curved  needle. 
This  secures  the  closure  of  the  external  ring,  and  fixes  the 
ligament,  without  strangulating  it.  The  assistant  lets  go  of 
the  ends  of  the  ligaments  after  they  have  been  fixed,  and  these 
ends  are  cut  short.  The  stumps  of  the  ligaments  are  stitched 
into  the  wound  by  means  of  the  sutures  which  close  the  incision. 
Dr.  Alexander  always  inserts  a  drainage-tube  and  washes  out 
the  wound  with  carbolic  lotion  before  tying  the  sutures.  The 
wound  may  be  dressed  after  any  accepted  method,  according  to 
the  opinions  of  the  operator.  Then,  in  cases  of  retroversion 
and  prolapse,  a  Hodge's  pessary  is  placed  in  the  vagina,  and 
the  sound  is  removed.  Other  precautions  of  this  kind  are 
taken  by  different  operators,  in  accordance  with  their  belief  as 
to  the  action  and  utility  of  special  stems  and  pessaries. 

The  patient  is  put  to  bed  with  her  knees  bent  over  a  pillow. 
Dr.  Alexander  says,  "  The  after-treatment  of  the  operation  con- 
sists in  rest.  The  wound  I  generally  dress  on  the  second  day, 
when  I  remove  the  tubes,  the  small  aperture  left  where  they 
are  removed  being  sufficient  to  maintain  the  necessary  drain 
in  most  cases.  The  ligaments  should  be  allowed  time  to  unite 
to  the  wound,  to  the  pillars  of  the  ring,  to  the  canal ;  and  for 
this  purpose  three  weeks  is  quite  short  enough  time.  Several 
of  my  private  patients  have  taken  a  longer  rest,  and  with 
benefit,  as  thus  all  the  pelvic  organs  have  become  accustomed  to 
their  new  position.  The  rest  need  not  be  in  bed — a  sofa  and 
the  sitting  posture  may  vary  the  monotony  of  lying  in  bed  ; 
whilst  sewing,  reading,  and  other  feminine  arts  may  be  indulged 
in  after  the  fn-st  few  days." 

In  cases  of  retroflexion.  Dr.  Alexander  inserts  a  galvanic 
stem  "  to  keep  the  uterus  straight  diuing  the  healing  of  the 
wound."  He  further  declares  that  this  stem  is  only  apjjiied  for 
mechanical  purposes. 

Dr.  Alexander  thus  sums  up  his  results :  "  A.s  regards  my 
own  practice,  I  can  honestly  say  that  I  have  never  yet  met  with 
a  relapse  of  any  backward  displacement  after  this  had  been 
placed  in  position  by  the  operation."     In  26  out  of  27  cases  of 


Alexander's  operation.  417 

retroflexion  and  retroversion,  no  relapse  occurred.  "  In  pro- 
lapse the  mechanical  results  have  also  been  nearly,  although 
not  quite  so  favourable.  I  have  operated  on  sixteen  cases, 
and,  strange  to  say,  my  penultimate  case  has  failed  completely, 
whilst  all  the  others  have  been  successes.  .  .  .  Some  of  my 
hospital  prolapse  cases  I  have  never  seen  after  they  left 
hospital,  but  the  majority  I  have  examined  again  and  again." 

Dr.  Alexander  admits  that  he  has  lost  one  case,  where  the 
nurse  had  been  attending  a  patient  with  pyaemia.  Two  more 
deaths  had  occurred,  to  his  knowledge, — -one  in  America,  the 
other  in  the  practice  of  a  Liverpool  surgeon. 

On  the  other  hand,  Mr.  Lawson  Tait  considers  that  although 
the  shortening  of  the  round  Hgaments  is  easily  effected,  and  is 
an  efficient  remedy  for  retroversion,  the  operation  is  dangerous. 
A  case  in  his  own  practice  nearly  died.  Dr.  Munde  admits 
that  he  has  in  two  instances  failed  to  find  the  ligaments. 


E   E 


418 


CHAPTEE  XYI. 

OPERATIONS    FOR    THE    RELIEF   OF    URIXARY    FISTULiE.    RECTO- 
YAGIXAL   FISTULiE.    AND   ECTOPIA   VESICA. 

Vesico- Vaginal  Fistula  and  Allied  Aflfections.  — Under 
this  heading  I  in  chide  all  fistulous  communications  between  the 
vagina  and  the  urinaiy  tract.  An  abnormal  channel  of  this 
kind  generally  opens  into  the  bladder,  and  this  condition  is 
termed  a  vesico-vaginal  fistula.  The  vagina  may,  however,  be 
brought  by  disease  or  accident  into  communication  with  the 
lu'ethra  (urethro-vaginal  fistula)  or  with  one  ureter  (ui'etero- 
vaginal  fistula). 

Causes.  — These  fistulse  may  be  the  result  of  cancer  of  the 
uterus.  In  such  cases  they  occur  in  subjects  who  are  hui't 
jDast  all  surgery.  By  far  the  most  frequent  cause  is  damage  to 
the  anterior  wall  of  the  vagina  during  labour-.  Since  en- 
lightened principles  have  universally  prevailed  in  this  countr}" 
amongst  obstetricians,  vesico-vaginal  fistula  has  become  a  rare 
affection.  Its  worst  forms  are  to  be  seen  amongst  semi- 
civiHzed  or  barbarous  nations,  where  laboiu'  is  habitually  mis- 
managed, amongst  sections  of  society  where  women  are 
ill-cared  for  or  personall}'-  careless,  and  lastly,  in  cases  where, 
for  sad  and  self-evident  reasons,  the  patient  hides  herself 
dui'ing  labour  and  conceals  her  condition.  The  worst  case  that 
I  ever  saw  was  that  of  a  girl  of  seventeen  who  had  lived  for 
several  years  amongst  gyjisies  and  other  vagrants,  and  after 
being  in  labour  for  three  or  four  days,  was  admitted  into  a 
country  workhouse.  She  was  totall}'  ignorant  of  the  real 
nature  of  her  condition.  On  the  fifth  day  she  was  dehvered 
of  a  stillborn  child.  The  upper  part  of  the  anterior  wall  of 
the  vagina  sloughed  away,  and  almost  complete  atresia  ^vith 


CAUSES    OF    YESICO-VAGINAL    FISTULA.  419 

vesico-vaginal  fistula  resulted.  Cases  nearly  as  bad  are  occa- 
sionally seen  in  remote  country  districts  where  the  patients  are 
delivered  without  medical  assistance,  and  careless  midwives 
may,  both  in  town  and  country,  be  responsible  for  this  accident. 
The  fistula  is  produced  by  damage  to  the  vesico-vaginal  sep- 
tum through  continuous  compression  between  the  child's  head 
and  the  pelvic  walls.  If  the  pressure  be  violent,  the  tissues  may 
be  irreparably  damaged  within  half-an-hour  ;  but,  as  a  rule,  the 
condition  is  brought  on  by  very  prolonged  compression.  A  full 
bladder  increases  all  risks  of  this  kind.  Once  many  obste- 
tricians laid  the  blame  of  the  accident  upon  forceps,  now  it  is 
generally  admitted  that  the  injuries  which  produce  fistula  are 
due  to  neglect  of  its  use,  or  to  its  being  employed  too  late.  If 
the  forceps  caused  serious  injuries  to  the  soft  parts,  we  should 
expect  to  find  such  injuries  laterally,  and  not  in  the  direction 
of  the  bladder ;  on  the  other  hand,  the  damage  caused  by 
pressure  of  the  foetus  and  the  site  of  the  damage  explain 
themselves,  as  repeatedly  testified  by  clinical  experience. 
Whenever  the  forceps  is  used,  however,  the  bladder  may 
certainly  be  injured  if  the  urine  be  not  drawn  off  beforehand. 

Injuries  from  foetal  bones  during  craniotomy  and  the 
incision  of  a  cystocele,  mistaken  for  the  bag  of  waters,  have 
been  known  to  cause  vesico-vaginal  fistula.  Deroubaix  has 
traced  the  affection  to  ulceration,  arising,  as  a  rule,  from  some 
small  wound  of  the  vagina  inflicted  during  childbirth,  but  pos- 
sibly in  some  cases  in  a  more  spontaneous  manner.  This 
ulcerative  process  increases,  until  a  fistula  is  formed.  It  is, 
according  to  Deroubaix,  most  frequently  observed  diu'ing 
epidemics  of  puerperal  fever.  In  most  cases  of  vesico-vaginal 
fistula,  it  must  be  remembered,  the  urine  does  not  escape 
through  the  new  passage  dii'ectly  after  the  injiuy,  as  the 
damaged  tissues  do  not  break  down  at  once. 

Vesico-vaginal  fistula  may  also  be  caused  by  the  constant 
pressure  of  a  pessary  for  many  months,  or  through  damage 
more  rapidly  produced  by  an  instrument  badly  made  or  too 
large.  Hence  the  necessity  of  warning  patients  against 
wearing  a  pessary  over  two  months.  A  patient  soon  gets  used 
to  the  instrument,  and  finds  or  believes  that  it  is  doing  her 
good.     Then,   she  may  even  forget  all  about  it,  and  when  it 


420      OPERATIONS    FOR    RELIEF    OF    URINARY    FISTUL.^,    ETC. 

begins  to  damage  the  vesico-vaginal  septum,  she  is  apt  to  think 
that  the  consequent  pain  and  irritation  is  "  the  womb,"  or 
"  ulceration." 

Vesico-vaginal  fistula  is  also  caused  by  wounds  made  with 
surgical  or  other  instruments,  from  sharp-pointed  foreign 
bodies  in  the  bladder,  and  from  abscesses  in  the  septum. 

Pathology. — The  surgeon  will  perceive,  from  the  above 
recapitulation  of  the  causes  of  vesico-vaginal  fistula  that  it 
may  be,  at  first,  a  clean-cut  wound,  but  that,  as  a  rule,  espe- 
cially in  the  great  majority  of  cases,  namely  those  where  the 
fistula  arises  through  injuries  received  during  labour,  there  is 
loss  of  tissue.  Again,  the  fistula,  even  if  caused  by  the 
cleanest  wound,  is  constantly  irritated  by  the  passage  of  urine. 

The  fistula  may  be  very  minute,  or  may  involve  a  more  or 
less  extensive  area  of  the  vesico-vaginal  septum.  Its  margin 
is  swollen  and  irregular  at  first,  but  ultimately  becomes  smaller, 
thin  and  tough  through  the  formation  of  cicatricial  tissue.  The 
"vesical  mucous  membrane  bulges  into  large  fistuloe,  so  as  to 
form  a  red  mass  which  can  be  seen  from  the  vagina.  The 
bladder,  if  the  urine  escapes  freely  through  the  fistula,  becomes 
permanently  contracted  and  thickened,  the  urethra  also  con- 
tracts and  may  even  become  impervious.  Another  serious 
complication  is  contraction  of  the  vagina  through  cicatrices 
■caused  by  other  injuries  during  childbirth. 

A  very  troublesome  condition  is  that  where  the  ureters  are 
involved  in  the  fistula.  This  may  occur  in  a  large  fistula,  or  in 
a  small  fistulous  opening  situated  somewhat  laterally  in  the 
anterior  vaginal  wall.  Sometimes  a  fistula  in  the  anterior 
vaginal  fornix  is  very  small,  and  allows  for  the  protrusion  of  the 
■orifice  of  one  of  the  ureters  only.  This  is  called  uretero-rnginal 
Jistula.  The  urine  may  sometimes  be  seen  trickling  from  the 
orifice  of  a  ureter  exposed  in  a  large  fistula. 

The  vulva  becomes  excoriated  and  swollen,  and  the  integu- 
ments of  the  thighs  erythematous,  through  the  constant  escape 
of  urine. 

Symptoms. — The  inability  to  retain  urine,  which  in  cases 
occurring  through  injury  diu'ing  laboiu*  does  not  come  on,  as  a 
rule,  till  the  slough  separates,  is  the  cardinal  symptom  of  vesico- 
vaginal fistula.     Irritation  of  the  integuments  produced  by  the 


DIAGNOSIS    OF    VESICO- VAGINAL    FISTULA.  421 

dribbling  of  mine  over  tbe  vulva,  and  an  odour  characteristic 
of  incontinence  of  urine,  are  seldom  absent,  though  in  some 
forms  of  fistula  the  dribbling  is  not  so  constant  as  in  others. 
The  constitution  soon  becomes  impaired.  In  certain  cases 
menstruation  is  suppressed,  returning  after  cure  by  operation,  as 
though  the  fistula  caused  amenorrhoea  in  some  manner  more 
direct  than  the  production  of  pure  debility.  Dyspareimia  is 
frequent,  partly  through  vaginismus,  a  direct  result  of  the  local 
irritation,  and  sterility  is  said  to  be  very  common  in  such  cases, 
through  damage  to  the  spermatozoa  from  its  admixtui'e  with 
urine  in  the  vagina.  The  discomfort  and  uncleanliness  involved 
in  this  affection  make  even  timid  patients  anxious  for  surgical 
relief. 

Diagnosis. — Incontinence  of  urine  may  follow  labour,  from 
over-distension  of  the  bladder,  and  from  other  causes  besides 
the  affection  now  being  considered ;  still,  this  symptom  when 
it  follows  childbirth,  is  always  in  the  highest  degree  suggestive 
of  vesico-vaginal  fistula.  On  making  a  digital  exploration  of 
the  vagina,  the  fistula  may  sometimes  be  detected ;  a  sound 
should  be  passed  into  the  bladder  and  held  in  the  left  hand,  at 
the  same  time.  The  sound  may  be  made  to  pass  through  the 
fistula,  so  that  its  point  touches  the  right  forefinger  in  the 
vagina.  If  no  fistula  be  detected,  a  distinct  puckering  in  the 
anterior  fornix  is  suspicious.  In  most  cases,  however,  unless 
the  fistula  be  very  large,  it  cannot  be  readily,  if  at  all,  discovered 
by  digital  exploration  of  the  vagina.  Nevertheless,  this  method 
must  never  be  neglected,  however  confident  the  surgeon  may 
feel  about  diagnosis,  not  even,  indeed,  v/hen  he  has  previously 
been  informed  by  a  colleague  on  whom  he  relies,  that  a  vesico- 
vaginal fistula  exists.  The  condition  of  the  pelvic  viscera 
must  be  systematically  explored,  as  other  diseases  may  be 
present. 

Exploration  of  Vagina  in  Cases  of  Suspected  Fistula. 
— This,  however,  must  always  remain  the  essential  part  of  the 
diagnosis.  The  vagina  may  be  explored  when  the  patient  lies 
in  the  semi-prone  position  (see  page  57),  and  then,  with  the 
aid  of  the  volsella,  which  draws  down  the  uterus  (page  76),  a 
fistula  high  up  in  the  anterior  fornix  may  conveniently  be 
inspected.     Lithotomy  position  is,  however,  the  best  for  this 


422   OPERATIO>'S  FOR  RELIEF  OF  URINARY  FISTUL.*!,  ETC. 

pm-pose,  as  it  is  the  easiest  for  inspecting  the  parts  in  a  good 
light,  and  is  that  in  which  the  operation  must  be  performed,  so 
that  tlie  surgeon  will  be  best  able  to  judge  of  the  accessibiKty 
of  the  fistula  when  the  patient  is  placed  in  this  position. 

The  patient  shoidd  therefore  be  placed  in  lithotomy  position, 
in  a  part  of  the  room  where  a  good  light  can  be  obtained. 
A  Sims'  speculum  (page  62)  is  then  passed  along  the 
posterior  vaginal  wall,  and  a  sound  is  introduced  into  the 
bladder.  The  anterior  wall  miist  be  carefully  searched.  Some- 
times a  large  piece  of  deep-red  vesical  mucous  membrane 
protrudes  through  the  fistula  ;  generally  the  fistula  can  be  seen, 
but  there  remain  cases  where  its  discovery  is  a  matter  of  great 
difficulty,  even  though  the  concavity  of  the  speculum  keeps 
filling  -with,  urine  during  the  examination.  Sometimes  the 
fistula  is  hidden  behind  a  fold  or  a  puckering  of  the  mucous 
membrane.  Fistulae  high  in  the  vagina  are  very  hard  to  detect. 
The  folloT^dng  method  is  the  best  to  adopt  in  these  cases,  or 
indeed,  in  all,  for  these  fistulse  may  be  multiple.  Clean  the 
vaginal  mucous  membrane  with  pledgets  of  wool  applied  by 
means  of  speeidum-forceps ;  then  clean  the  cervix  by  the  aid 
of  a  Playfair's  probe  with  wool  wrapped  round  its  point.  The 
OS  externum  is  plugged  mth  cotton- wool  apphed  dry.  Warm 
milk  is  then  injected  into  the  bladder,  and  the  vagina  is  watched. 
If  a  vesico-vaginal  fistula  be  present,  the  white  fluid  dribbling 
from  it  will  soon  betray  its  position.  If  no  milk  di'ibbles  away 
from  the  vaginal  walls,  but  the  plug  in  the  cervix  is  found 
to  be  soaked  in  that  fluid,  and  especially  if  the  milk  is  seen  to 
escape  from  the  os  externum,  the  fistula  is  vesico-uterine. 
When  this  experiment  fails  to  detect  any  fistula,  yet  the 
involuntary  escape  of  urine  is  still  evident  and  not  accounted 
for  by  incontinence  of  a  less  mechanical  kind,  there  may  be 
a  urelero-vaginal  or  uretero-uterine  fistula,  with  the  vesical 
mucous  membrane  acting  as  a  valve  so  as  to  prevent  the  escape 
of  the  milk.  For  these  comparatively  rare  lesions  Berard's 
test  should  be  employed.  This  test  is  based  on  the  principle 
that  the  urine  escaping  from  the  ureter  involved  in  the  fistula 
runs  away  through  the  vagina,  whilst  that  which  issues  fi'om 
the  opposite  ureter  distends  the  bladder.  The  patient's  urine 
is  first  drawn  off,  and  then  she  is  placed  for  two  hours  over 


DIAGNOSIS    OF    URETERIC    FISTULA.  4"23 

a  nigMstool  made  as  comfortable  as  possible,  being  at  the  same 
time  strictly  ordered  not  to  empty  her  bladder  voluntarily.  At 
the  end  of  that  time,  the  urine  which  has  escaped  invohmtarily 
is  measured,  and  then  that  which  remains  in  the  bladder  is  di'awTi 
off,  or  the  patient  may  be  allowed  to  pass  it.  If  the  amount  of 
urine  passed  by  the  former  way  is  about  equal  to  that  passed 
by  the  latter,  then,  especially  if  each  amount  be  considerable, 
— that  is,  over  four  or  five  ounces, — there  will  be  strong  evidence 
of  a  ureteric  fistula.  A  fresh  examination  of  the  vagina  will 
be  necessary,  and  careful  search  must  be  made  near  the  cervix 
laterally.  The  urine  may  possibly  be  then  seen  escaping  in 
intermittent  jets ;  and  sometimes  a  fine  probe  may  be  passed 
into  the  ureter.  In  any  case,  however,  these  fistulee  are  hard 
to  detect.  When  a  uretero-vaginal  fistula  cannot  be  found,  the 
surgeon  must  dry  the  cervix  with  wool,  and  watch  it  through 
a  Fergusson's  speculum  for  some  time,  endeavouring  to  see  if 
urine  escapes  from  it.     If  so,   a  uretero-uterine  fistula  exists. 

Sometimes,  the  fistida  is  urethro -vaginal ;  in  these  cases  there 
is  often  but  little  incontinence  of  urine,  as  the  muscular  fibres 
of  the  urethra  aid  in  the  retention  of  that  fluid.  In  this  form  of 
fistula,  however,  the  lower  part  of  the  bladder  is  generally 
involved. 

Whenever  a  distinct  vesico-vaginal  fistula  extends  laterally, 
the  surgeon  must  remember,  both  in  diagnosing  and  during 
operation,  that  a  ureter  is  very  near  to,  or  actually  involved  in 
the  fistula  (Fig.  11,  page  32). 

The  permeability  of  the  urethra  and  the  general  condition  of 
the  vagina  will  be  discovered  in  the  course  of  the  above  examina- 
tions. Urinary  salts  become  deposited  around  the  edges  of  these 
fistulse. 

Prognosis. — A  small  fistida  vdll  often  heal  spontaneously 
during  convalescence  after  childbirth,  especially  if  the  vagina 
be  kept  clean.  If,  however,  the  fistida  be  of  any  size,  so  that 
a  permanent  aperture  which  is  too  large  to  be  plugged  by 
protruding  mucous  membrane  exists,  it  is  most  unhkely  to  ciii-e 
spontaneously,  and  the  jD^tient  will  be  exposed  to  all  the 
miseries  which  this  disease  pf  necessity  produces. 

Treatment. — When  a  very  small  fistula  is  detected,  the 
vagina  should  be  kept  thoroughly  clean  by  fi-equent  syringing 


424      OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULiE,    ETC. 

with  warm  water.  A  catheter  must  be  retained  in  the  bladder:  a 
special  form  of  self -retaining  catheter  will  be  described  after  the 
accoimt  of  the  operation  for  repair  of  a  fistula  (page  434).  Emmet 
has  noted  that  in  two  cases  where  the  fistula  was  detected  immedi- 
ately after  deliver}'-,  and  was  in  each  case  large  enough  to  allow 
the  introduction  of  the  finger,  a  cm-e  was  effected  within  a 
month,  no  treatment  being  adopted  beyond  frequent  injections 
of  warm  water.  These  injections  must  always  be  kept  up,  even 
when  an  operation  is  intended,  as  they  promote  the  arrest  of 
morbid  processes  around  the  fistulse.  Attempts  to  heal  small 
fistulse  by  the  application  of  the  thermo-cautery  to  theii"  edges 
have  not,  as  far  as  I  have  seen,  met  with  good  results.  It  is 
more  successful,  I  beheve,  when  used  to  close  an  angle  of  the 
wound  formed  in  the  operation  for  the  repair  of  a  large  fistula. 

As  a  rule,  however,  a  vesico-vaginal  fistula  requires  to  be 
repaii'ed  by  a  plastic  operation.  Any  attempt  to  teach  the 
steps  of  an  operation  of  this  kind  by  verbal  directions  must  be 
to  a  great  extent  unsatisfactory,  and  this  fact  applies  v/itli 
particular  force  to  the  operation  for  repair  of  vesico-vaginal 
fistulse.  The  principles  of  the  operation  must  be  kept  in  mind. 
The  edges  of  the  fistula  are  to  be  made  raw,  and  then  imited 
with  sutm-es.  These  sutm'es  must  not  pass  thi'ough  the  vesical 
mucous  membrane,  else  the  needle-wouncl  may  set  up  trouble- 
some haemorrhage,  and  calculous  concretions  will  be  deposited 
along  the  sutm-es  as  they  lie  exposed  in  the  cavity  of  the 
bladder.*  The  sutures  must  be  tied,  and  when  the  fistula  has 
healed  they  must  be  removed.  Principles  of  this  kind  are 
amongst  the  easiest  to  lay  down  and  the  most  difficult  to  carry 
into  effect.  The  operation  always  demands  a  considerable 
amount  of  manual  dexterity. 

The  vagina  must  not  only  be  kept  clean,  but  it  must  be 
explored  for  any  complication.  Cicatricial  bands  in  the  vagina 
must  be  divided  with  scissors,  the  vagina  being  kept  open 
after^^'ards  by  means  of  a  dilator,  such  as  the  elastic  gum 
dilator  (Fig.  146)  used  for  vaginismus.     Calcareous  incrusta- 

*  A  specimen  of  a  calculus,  -with  a  wire  suture  as  its  nucleus,  is  in  the  collec- 
tion of  calculi  in  the  Museum  of  the  Royal  College  of  Surgeons.  This  kind  of 
calculus  can  also  lie  formed  if  the  operator  neglect  to  remove  all  the  sutures,  so 
that  one  or  more  ulcerates  into  the  bladder. 


PREPARATION  FOR  OPERATION.  426 

tions,  whicii  often  form  on  the  vaginal  mucous  membrane  and 
around  the  edges  of  the  fistula,  must  be  carefully  washed  away 
by  sponging  with  warm  water,  very  slightly  acidulated  with 
hydrochloric  acid;  about  five  minims  to  the  pint  will  be 
sufficient.  The  patency  of  the  urethra  must  be  ascertained, 
especially  in  old  cases,  where  it  is  always  more  or  less  contracted 
through  disuse.  Its  canal  must  be  dilated  to  the  normal 
calibre,  if  necessary.  When  the  urine  is  alkaline,  it  should  be 
rendered  acid  by  doses  of  boracic  or  hydrochloric  acid. 

The  surgeon  is  not  likely  to  forget  that  both  the  common 
form  of  vesico-vaginal  fistula,  following  child-birth,  and  that 
which  results  from  the  pressure  of  a  pessary,  involve  either  loss 
of  substance  or  at  least  a  very  morbid  condition  of  the  sur- 
rounding tissues.     In  this  lies  one  of  the  main  difficulties  of 


Fig.  146.— Elastic  Gum  A-'aginal  Dilator. 

the  operation.  A  simple  clean  wound  in  the  vesico-vaginal 
septum  is  not  very  difficult  to  heal  by  suturing. 

Dr.  Marion  Sims  advisedly  recommended  delay  of  the 
operation  till  a  few  months  after  delivery,  in  cases  where  the 
fistula  was  caused  by  injuries  received  during  labom\  Some 
Grerman  authorities  believe  that  the  operation  is  best  performed 
from  six  weeks  to  two  months  after  labom\  The  sm'geon» 
however,  does  not  always  see  the  patient  till  many  months  after 
the  formation  of  the  fistula. 

In  any  case  where  it  may  happen  to  be  ad\dsable  to  attempt 
the  repair  of  a  part  only  of  a  fistula  at  one  sitting,  reserving 
the  completion  of  the  repair  for  another  occasion,  the  patient 
should  not  be  kept  in  hospital  or  treated  as  an  invalid  between 
the  two  operations,  but,  on  the  contrary,  allowed  fresh  aii'  and 
exercise  as  soon  as  she  has  recovered  from  the  first. 


426       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTUL.T.,    ETC. 

The  Operation. — The  general  princiiDles  have  been  already 
given ;  but  there  are  two  distinct  methods  in  vogue  at  the 
present  day.  The  first  is  the  American  or  Sims'  operation. 
In  this  procedure  the  edges  of  the  fistula  are  pared  obliquely, 
and  particular  care  is  taken  not  to  involve  the  vesical  mucous 
membrane  ;  the  fistula  is  closed  with  silver  wire,  and  a  catheter 
is  retained  in  the  bladder.  The  second  is  the  Grerman  or 
Simon's  operation.  Here,  the  edges  of  the  fistula  are  pared 
vertically,  the  mucous  membrane  of  the  bladder  not  being 
siieeially  respected ;  silk  sutures  are  used,  and  the  patient  is 
allowed  to  pass  her  urine  voluntarily,  the  catheter  being  only 
employed  to  prevent  great  distension  of  the  bladder.  The 
differences  are,  with  one  exception,  confined  to  matters  of 
detail.  A  modified  variety  of  the  American  operation,  as 
practised  by  Sims  and  Bozeman,  -will  be  described. 

Position. — The  general  siu'geon  ^dll  probably  prefer  to 
operate  with  the  patient  placed  in  the  lithotomy  position,  and 
this  is  always  the  most  convenient  for  the  handling  of  the 
Sims'  speculum  by  the  assistant,  for  the  chloroformist,  and  for 
the  operator  also,  provided  that  the  fistula  lies  in  a  position 
easily  reached  by  the  knife  and  sutiu-e-needle,  when  the  patient 
is  placed  on  her  back.  Sometimes,  however,  the  lateral  or 
semi-prone  (page  57)  position  will  be  necessary.  Dr.  Bozeman 
prefers  the  genupectoral,  and  fixes  the  patient  in  that  position 
by  means  of  a  special  apparatus.  Few  sm^geons,  however,  who 
are  not  specialists,  are  likely  to  attemi:)t  to  operate  with  the 
patient  so  placed.  I  must  here  refer  to  the  observations  on  the 
genupectoral  position  at  page  57. 

In  the  follo'W'ing  description  the  patient  is  supposed,  through- 
out, to  be  on  her  back.  The  bowels  must  be  thoroughly  cleared 
out  by  a  laxative  adnainistered  about  forty-eight  hours  before 
operation,  followed  by  an  enema  shortly  before  the  patient  is 
laid  on  the  table. 

The  patient  is  brought  under  the  influence  of  the  anaesthetic. 
Then,  her  knees  are  kept  apart  by  means  of  a  Clover's  crutch 
(page  132).  The  vagina  is  syringed  out,  and  the  blade  of  a 
Sims'  specuhmi  (page  62)  is  passed  along  its  posterior  wall. 
An  assistant  holds  the  speculum  in  place  with  his  right  hand 
during  the  remainder  of  the  operation. 


PARING    THE    FISTULA. 


427 


Paring  the  Fistula. — An  assistant  stands  on  the  left 
hand  side  of  the  operator,  bearing  a  sponge-holder  (Fig.  147). 
The  sponge  itself  should  he  very  small.  The  best  form  of 
knife  is  a  small  straight  scalpel,  mounted  on  a  long  polygonal 


Fig.  147. — Sponge-Holder. 

handle,  something  like  the  uppermost  in  Fig.  148.  The  lower 
knives,  bent  on  their  handles,  are  difficult  to  manipulate 
without  much  practice.  Two  light  pairs  of  long-handled 
scissors,  one  with  curved,  the  other  with  straight  blades,  will 
be  required ;  they  are  very  convenient  for  detaching  the  last 
piece  of  tissue  from  the  part  whence  it  is  dissected.  The  old 
idea  that  scissor- wounds  cannot  heal  by  first  intention  is  quite 
false,  as  long  as  sharp  instruments  are  used. 


Fig.  148. — Vesico-Vaginal  Fistula  Knives. 
The  lines  at  the  side  of  the  blades  indicate  the  angles  at  which  they  are  bent. 

The  vaginal  mucous  membrane  is  caught  up  close  to  the 
edge  of  the  fistula  by  means  of  a  simple  tenaculum,  with  a 
wide  curve.  This  instrument  is  more  handy  than  special  con- 
trivances employed  by  individual  authorities.  Long-shanked 
tenaculum-forceps  tire  the  left  thumb  and  forefinger  if  held, 
and  tear  away  the  tissues  if  left  dependent.  The  mucous 
membrane  is  then  cut  away  obliquely  and  evenh^  to  the  extent 
of  about  one-eighth  of  an  inch.    The  lower  border  should  be  cut 


428   OPERATIONS  FOR  RELIEF  OF  URINARY  FISTUL.'E,  ETC. 

fii'st,  SO  that  blood  may  not  obscm-e  the  parts  as  they  are  being- 
thinned.  Care  must  be  taken  to  so  handle  the  tenaculum  that 
the  lateral  parts  of  the  fistula  may  be  pared,  and  to  avoid 
woimding  the  vesical  mucous  membrane,  as  this  accident  causes 
haemorrhage  into  the  bladder.  The  strip  of  tissue  should  be 
cut  away  in  one  piece,  if  possible,  else  a  minute  portion  of 
vaginal  mucous  membrane  may  be  left  behind,  and  so  prevent 
union.  The  more  the  fistula  lies  centrally  with  its  long 
diameter  transverse,  the  easier  will  be  the  paring  and  the 
subsequent  processes,  if  the  patient  lie  in  the  lithotomy  position, 
as  the  handles  of  the  instruments  will  not  be  impeded  by  the 
position  of  the  patient's  thighs.  When  the  fistula  lies  high  up, 
or  considerably  to  one  side  of  the  middle  line,  the  relations  of 
the  ureter  (page  31)  must  be  borne  in  mind. 

Dming  this  process  the  assistant  who  has  charge  of  the 
sponge-holder  must  keep  cleaning  the  part  subjected  to  opera- 
tion, in  such  a  manner  as  to  prevent  the  haemorrhage  from 
interfering  with  the  operator,  without  at  the  same  time  causing 
still  greater  obstruction  by  appljdng  the  sponge  to  the  wound 
at  the  wrong  moment.  This  sponging  must  be  performed  very 
gently,  else  the  strip  of  tissue  in  process  of  removal  may  be 
torn,  or  brushed  off  from  the  tenaculum.  Should  the  operator 
distrust  the  skill  of  his  assistant,  it  will  be  advisable  for  him  to 
use  the  sponge-holder  himself,  making  the  assistant  hold  the 
scissors  w^hilst  so  employed.  Severe  haemorrhage,  very  rare  if 
the  operation  be  properly  performed,  wall  require  free  syringing 
wdth  hot  water,  and  spouting  arteries  demand  torsion  or  liga- 
ture. It  is  unadvisable  to  apply  ligatui'es  if  this  can  possibl}" 
be  avoided,  particularly  if  a  vessel  bleed  in  the  direction  of  the 
vesical  mucous  membrane  so  that  there  is  a  risk,  not  only  of 
interference  with  the  imion  of  the  edges  of  the  fistula,  but  also 
of  calculous  concretions  round  the  knot  of  the  hgature.  Hence 
it  is  a  good  plan  to  secure  the  vessel  -wdth  pressm^e-forceps 
(page  94),  and  to  wait  a  few  minutes  should  the  instrument 
interfere  with  further  proceedings.  As  a  rule,  this  will  be 
sufficient,  and  the  tying  of  the  sutures  will  check  further 
bleeding. 

Protrusion  of  Vesical  Mucous  Membrane.— In  large 
fistulae  this  protrusion  is  often  very  troublesome,  the  mucous 


APPLICATION    OF    THE    SUTURES.  429 

membrane  getting  into  the  surgeon's  way,  interfering  with  the 
paring  process,  and  subjecting  itself  to  great  risk  of  injurj^ 
from  the  scissors  or  suture-needles.  It  may  be  kept  back 
with  a  sponge  introduced  into  the  bladder,  so  that  the  sutures 
are  applied  over  it,  very  much  as  in  ovariotomy  before  the 
abdominal  wound  is  closed ;  the  sponge  must  be  pulled  out  at 
the  last  moment  before  the  sutures  are  tied. 

Application  of  the  Sutures. — This  process  is  yet  more 
delicate  than  the  paring  of  the  edges.  Sometimes  a  hollow 
tubular  needle  is  used ;  but  this  instrument  is  not  very  trust- 
worthy, as  in  spite  of  all  precautions  the  silver  wire  or  silkworm- 
gut  will  not  always  run  freely  through  it,  just  when  rec[uired. 
The  simplest  contrivance  is  a  handled  needle,  with  an  eye  near 
the  point  which  is  curved  but  slightly,  or  rather  bent  at  a  very 
obtuse  angle ;  this  is  employed  by  Dr.  Percy  Boulton  (Fig. 
149).     It   is   most   suitable   for  the  application  of  silver  wire 


Fig.  149. — Ve.sico-Va(;ixal  Fistula  Needle.     {Boulton.) 

sutures ;  but  this  question  of  the  best  material  for  suture  will  be 
explained  more  fully  when  I  come  to  speak  of  the  process  of 
tying  threads.  The  handle  of  the  needle  is  held  in  the  right 
hand,  in  front  of  the  anterior  part  of  the  vulva;  the  point, 
directed  downwards,  is  entered  near  the  outer  margin  of  the 
upper  (anatomically  the  lower)  border  of  the  wound,  as  far 
external  to  it  as  the  width  of  the  denuded  surface.*  It  is  then 
pushed  through  the  tissues,  emerging  close  to  the  vesical 
mucous  membrane,  which  must  not  be  included  in  the  suture 
(Fig.  150).  The  point  of  the  needle  then  enters  the  opposite 
side  of  the  wound  at  a  spot  corresponding  with  the  point  of 
exit,  and  traverses  a  corresponding  tract  of  tissues.  A  blunt 
hook  (Fig.  151)  is  very  useful  in  making  counterpressure 
against  the  point  of  the  needle  when  the  tissues  are  dense.     It 

*  When  the  sutures  are  inserted  too  far  from  the  edge  of  the  wound,  the 
mucous  membrane  will  be  turned  in  when  they  are  tied.  This  condition  will 
greatly  hinder  union. 


430       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULJE,    ETC. 


Fig.  150. — Opekation  for  the  Repair  of  A''e.sico-Vaginal  Fistula. 
Passaste  of  the  needle  througli  the  edges  of  the  fistula,  for  introduction  of  suture. 


Fi(!.  1.51.— Blunt-hook  for  Vesico-Vaginal  Fistula  Operation.    (Boidton.) 


*'  In  this  drawing,  which  I  .sketched  during  an  operation,  the  posterior  vaginal 
wall  is  seen  to  be  depressed  by  the  blade  of  a  Sims'  speculum.  The  labia  are 
supposed  to  be  kept  apart  by  the  lingers  of  assistants.  In  some  illustrations 
which  follow,  and  which  are  taken  from  foreign  publications,  the  labia  are 
diawn  with  retractors  applied  to  them,  so  as  to  keep  the  vulvar  aperture  ojicn. 


APPLICATION    AND    TYING    OF    THE    SUTURES. 


431 


avoids  the  danger  of  tearing  the  wound,  and  facilitates  the 
issue  of  the  point  of  the  needle  at  the  desired  spot.  When  the 
eye  of  the  needle  is  pushed  far  enough,  the  wire  is  passed  through 
it  and  the  needle  then  withdrawn,  so  that  the  wire  occupies  its 
former  track.  I  meed  not  refer  to  the  innumerable  modifications 
of  this  stage  of  the  operation  suggested  or  practised  by  ingenious 


Fig.  152. — The  Sutures  aftek  Introduction.     (Simon.) 

specialists.  The  remaining  sutures  are  passed  in  the  same  manner 
till  the  wound  appears  as  in  Fig.  152. 

Tying  the  Sutures. — In  the  above  directions  for  the 
different  stages  of  the  operation  the  question  of  the  material 
used  for  the  purposes  of  suture  has  been  left  open,  excepting 
that  the  choice  has  been  limited  to  silver  wire  and  silkworm- gut. 
This  question  is  perhaps  most  important  in  regard  to  the  stage 
now  to  be  described.  Silkworm-gut,  well  soaked  in  water,  is 
an  excellent  material.  It  may  be  secured  without  the  aid  of  any 
instrument,  the  ends  of  each  suture  being  tied  together  in  a 


432   OPERATIONS  FOR  RELIEF  OF  URINARY  FISTUL.^E,  ETC. 

double  reef-knot,  firmly  but  not  tightly,  so  as  to  bring  the  edges 
of  the  fistula  well  together.  This  manoeuvre  is,  however,  not 
easy  when  the  fistula  is  high  and  the  vagina  narrow.  For  the 
relatively  inexperienced  operator  No.  4  or  No.  6  silver  wire  is 
the  better  material  for  the  purpose,  and  many  experienced 
specialists  employ  it.  In  order  to  tie  a  wire  suture,  the  two 
ends  are  fii'st  dra"v\Ti  downwards  to  make  them  tense,  so  as  to 
avoid  kinking,  and  held  in  the  left  hand.  The  surgeon  takes, 
in  his  right,  an  S-headed  suture-twister  (Fig.  153),  and  one 


Fig.  153.— S-headed  Sutuke-Twister. 


end  of  the  suture  is  slipped  into  one  of  the  concavities  of  the  S, 
the  other  concavity  receiving  the  other  end.  The  twister  is  then 
slid  along  the  two  ends  (Fig.  154)  and  gently  rotated  four  or 


Fig.  154. — The  S-headed  Twister  ix  Use. 


five  times  close  to  the  fistula,  so  as  to  bring  its  edges  into  appo- 
sition, without  the  least  tension.  When  all  the  sutures  have 
been  secured,  the  ends  are  twisted  together  half-an-inch  below 


Fig.  155. — The  Wires  Twisted  and  Secured. 

the  fistula  and  cut  short.  They  then  lie  very  conveniently  for 
subsequent  proceedings,  and  cause  no  irritation  of  the  vagina. 
Before  twisting  them,  they  should  be  grasped  in  the  blades  of 
a  pressure-forceps,  so  as  to  avoid  any  dragging  on  the  tissues 
around  the  fistula  (Fig.  155). 

It  will  now  be  seen  that,  as  has  been  already  noted,  it  is 
easier  to  apply  and  tie  the  sutures  when  the  fistula  runs  trans- 
versely  to    the   operator,    the   patient    lying  in  the  lithotomy 


CATHETERISM  AFTER  OPERATION,  433 

position.  If  tlie  fistula  be  vertical,  the  needle  and  twister  have 
to  he  passed  laterally,  then  the  patient's  thighs  will  greatly 
impede  manipulation.  In  such  a  case,  the  semi-prone  j)osition 
(page  57)  may  he  convenient. 

"When  the  fistula  is  wide  and  irregular,  it  sometimes  requires 
to  he  closed  in  a  T-shaped  form.  The  horizontal  or  vertical  bar 
should  be  pared  and  closed  first,  the  other  portion  being  repaired 
at  a  subsequent  operation,  after  the  patient  has  been  sent  for  a 
hohday  and  well  fed  (page  425).  Simon  has  often  ojoerated 
with  great  success  in  this  manner. 

Conclusion  of  the  Operation. — When  all  the  sutures 
have  been  tied,  the  bladder  is  washed  out  with  warm  water. 
This  clears  it  of  any  blood  which  may  have  escaped  into  its 
cavity,  and  allows  the  operator  to  ascertain  if  the  fistula  be 
securely  closed.  If  any  water  escape  through  it,  an  additional 
suture  or  two  will  be  required. 

Catheterism. — Professor  Simon  and  many  other  experi- 
enced  living   authorities   reject   the   principle    of  retaining    a 


Fig.  156. — Self-ketaixing  Catheter  for  Urethro-Vagixal  axd  Tesico- 
Urethro-Vagixal  Fistul.e.     [Boulton.) 

catheter  after  this  operation.  They  order  the  nurse  to  di-aw 
off  the  urine  about  every  six  houi'S  for  the  first  two  days, 
and  afterwards  allow  the  patient  to  micturate  voluntarily. 
The  management  of  Sims'  stationary  catheter  requires  great 
experience  on  the  part  of  the  nurse,  and  even  then  it  does 
not  always  act  in  a  satisfactory  manner.  If  its  point  should 
touch  the  fundus,  it  will  soon  .become  displaced,  and  though 
termed  stationary,  it  must  be  changed  dail}'-  and  thoroughly 
cleaned,  so  that  two  of  these  special  catheters  must  be  kept 
on  hand  for  one  patient. 

When,  however,  the  fistula   is   close   to  the   uretlu-a   or   is 

r   r 


434      OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULA,    ETC. 

uretlu'o-Yaginal  (more  will  be  said,  presentl}^,  on  this  variety) 
a  catheter  must  be  retained,  else  the  nurse,  however  skilful, 
must  disturb  the  seat  of  operation  whenever  she  attempts  to 
pass  that  instrument.  To  meet  requirements  in  cases  of  this 
kind,  Dr.  Boulton  uses  the  catheter  represented  in  Fig.  156. 
It  is  made  of  ^iilcanite.  It  measm^es  only  two  and  a  half 
inches  in  lengtJi,  and  is  therefore  too  short  to  press  against 
the  fundus.  The  bulbous  extremitj'*  prevents  it  from  sHpping 
out  of  the  bladder,  but  is  not  so  wide  in  diameter  as  to 
endanger  the  cicatrix  of  the  fistula  when  the  instrument  is 
removed.  It  is  perhaps  best  for  a  catheter  of  this  kind  to  be 
introduced  and  retained  after  any  operation  for  the  vesico- 
vaginal fistula  ;  certainly,  at  least,  when  the  most  skilled 
nursing  cannot  be  procm-ed.  This  catheter  may  be  worn  for 
a  month,  if  it  be  occasionally  removed  and  washed  in  a  strong- 
solution  of  acetic  acid  in  water. 

After-treatment. — The  patient  is  placed  in  bed  on  her 
left  side.  When  a  catheter  has  been  introduced,  under 
cheumstances  just  noted,  a  bed-pan  with  a  hollow  handle 
should  be  placed  in  the  bed  behind  the  bent  knees,  which 
must  be  tied  together  by  means  of  a  bandage.  A  piece  of 
flexible  rubber  tubing  is  fitted  on  to  the  catheter,  at  one  end, 
the  other  being  passed  into  the  bed-pan.  The  practice  of 
placing  the  patient  on  her  back  after  the  operation  is  open 
to  the  great  objection  that  any  receptacle  for  the  urine  is 
then  liable  to  be  pushed  out  of  place.  Tubing  passed  fi'om 
the  catheter  to  a  receptacle  kept  on  one  side  of  the  bed  will 
entail  a  great  deal  of  trouble,  and  even  then  may  fail  in  its 
object  of  facilitating  a  free  escape  of  urine. 

The  bowels  must  not  be  allowed  to  become  too  much  confined, 
so  as  to  cause  irritation  through  the  collection  of  hard  scybala. 
An  enema  should  be  thrown  up,  as  after  ovariotomy  (page  248), 
about  the  sixth  day,  before  the  removal  of  the  sutures. 

Unfavourable  Symptoms  after  Operation. — The  chief 
unfavourable  symptom  is  licemorrhage  into  the  bladder.  It 
may  often  be  checked,  at  the  beginning,  by  injections  of  warm 

*  In  most  other  fonu.s  of  self-retaining  catheter  the  bulb  is  made  too  large. 
This  renders  the  instrument  unfit  for  cases  of  urethral  fistula,  whilst  the  variety 
above  figured  is  ])eculiarly  fitted  for  that  aflection. 


UNFAVOURABLE    SYMPTOMS REMOVAL    OF    SUTURES.        435 

water,  but  if  vesical  irritation  increase  and  it  is  found  that  the 
bladder  is  distended,  yet  nothing  can  be  drawn  off  by  the 
catheter,  the  distension  must  be  due  to  clots,  and  the  fistula 
must  be  opened  again  and  the  clots  removed. 

The  gravest  accident  is  the  inclusion  of  the  ureter  in  a  stitch. 
This  danger  is  likely  to  occur  when  the  fistula  extends  con- 
siderably to  one  side.  The  ureteric  orifice  may  even  be 
stitched  up,  by  mistake,  as  a  fistula.  The  symptoms  are 
severe  pain  radiating  from  the  kidney  downwards  along  the 
course  of  the  ureter,  followed  by  all  the  phenomena  of 
uraemia.  In  such  a  case,  the  sutures  must  be  removed. 
This  has  been  done  with  the  effect  of  causing  the  dis- 
appearance of  all  the  above  symptoms. 

Cystitis  is  manifested  by  the  characteristic  changes  in  the 
urine,  pain  in  the  hypogastrium  and  great  desire  to  empty 
the  bladder.  The  tenesmus  which  accompanies  this  compKca- 
tion  is  very  prejudicial  to  the  healing  of  the  fistula.  Cystitis 
must  be  treated  by  the  usual  therapeutic  measures,  opiates  and 
diluents  being  administered.  The  bladder  should  be  frequently 
washed  out  with  warm  water  containing  about  ten  grains  of 
chlorate  of  potash  to  the  pint,  and  the  catheter  must  not  be 
retained. 

Removal  of  the  Sutures. — The  sutures  are  removed 
about  the  eighth  or  tenth  day.  The  patient  is  laid  on  the 
left  side,  and  a  Sims'  speculum  is  passed  along  the  posterior 
vaginal  wall  and  held  in  position  by  an  assistant.  Each 
twisted  end  is  grasped  by  a  dressing-forceps,  and  the  suture 
is  then  cut  above  the  knot  by  a  pair  of  long-handled  scissors. 
For  this  process  the  patient  should,  if  possible,  be  placed  on 
a  table  about  three  feet  high  and  in  a  good  light.  If  she 
should  persist  in  remaining  in  bed  the  manipulations  will  be 
very  troublesome. 

Imperfect  Union  of  the  Wound. — This,  if  extensive, 
must  be  treated  by  paring  and  suture  of  the  ununited  part. 
When  only  a  pin-hole  opening  exists,  it  may  be  closed  by 
cauterization.  For  this  purpose,  the  edges  are  touched  hj  a 
small  platinum  point  heated  by  the  battery.  This  platinum 
point  will  be  figured  together  with  the  instruments  which  are 
employed  for  cauterizing  urethi-al  caruncles  (page  471). 


436       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTUL.E,    ETC, 

Operations  allied  to  the  Closure  of  a  Simple 
Vesico-Vaginal  Fistula. — The  above  observations  refer  to 
cases  where  a  vesico-vaginal  fistula  is  not  very  large  nor  very- 
high,  and  where  its  edges  are  not  in  a  markedly  morbid  condi- 
tion, thin  and  atrophied,  or  thick  from  cicatricial  tissue.  The 
inexperienced  are  recommended  to  have  as  little  to  do  as  pos- 
sible with  more  complicated  cases.  They  may  baffle  the  most 
skilful  operators.  These  remarks  are  not  intended  to  glorify 
the  practice  of  specialists.  No  doubt  Sims,  Simon,  and  others 
have  been  enabled  to  make  advances  in  this  branch  of  plastic 
surgery  entirely  through  their  wide  experience  as  specialists. 
On  the  other  hand,  general  hospital  sm^geons,  Brj^ant,  Thomas 
Smith,  Langton,  and  many  other  operators  in  London  and  the 
provinces,  have  succeeded  in  curing  the  most  complicated  cases. 
Some  of  these  gentlemen  have  thought  good  to  publish  their 
results ;  others  have  not  done  so.  Whilst  profoundly  respecting 
the  motives  of  the  latter  class,  I  still  believe  that  the  history  of 
the  cure  of  complicated  cases,  at  least,  should  be  recorded. 

The  more  complicated  forms  of  fistula,  to  which  the  above 
remarks  refer,  are :  Fistula  near  the  cervix ;  m^ethral  fistula ; 
vesico-vaginal  fistula  with  atresia  of  the  urethra ;  vesico- 
uterine fistula ;  uretero-vaginal  and  uretero-uterine  fistula ; 
and  extensive  vesico-vaginal  fistula,  requiring  closure  of  the 
vagina  by  a  plastic  operation  ("  colpocleisis").  Recto-vaginal 
fistula  will  be  described  separately. 

Vesico-Vaginal  Fistula  near  the  Cervix  Uteri. — 
"When  a  vesico-vaginal  fistula  lies  so  high  in  the  anterior  fornix 
of  the  vagina  that  its  uppermost  border  is  uterine  tissue, 
Simon's  plan  may  be  adopted.  The  tissues  are  dissected  up  all 
round  the  fistula,  as  in  the  simpler  operation,  so  that,  in  this 
case,  a  portion  of  the  cervix  uteri  is  vivified.  Then,  the  sutures 
are  passed  through  the  anterior  lip  of  the  os  uteri,  and  through 
the  tissues  behind  the  vivified  lower  edge  of  the  fistula.  When 
the  sutures  are  tied,  the  anterior  lip  will  cover  up  the  fistula, 
bringing  the  raw  surfaces  on  the  cervix  and  on  the  lower  edge 
of  the  fistula  into  contact.  Provided  that  the  edges  of  the  fistula 
are  fairly  healthy,  this  operation  will  probably  be  successful. 
Passing  sutures  through  uterine  tissue  is,  it  must  be  remem- 
bered, a  practice  entailing  a  considerable  amount  of  risk. 


RARER    FORMS    OF    URINARY    FISTULA.  437 

Sometimes,  however,  a  fistula  of  this  kind  is  very  large,  or 
its  vaginal  borders  unhealthy,  and  its  uterine  aspect  in  a  yet 
worse  condition ;  in  fact,  there  may  he  great  loss  of  uterine 
tissue.  In  this  case,  some  authorities  recommend  that  the 
posterior  lip  of  the  os  be  sewn  to  the  lower  edge  of  the  fistula 
after  complete  and  wide  vivifying  of  the  edges ;  the  su.tures  are 
passed  just  in  the  same  manner  as  when  the  anterior  lip  is  in- 
cluded, a  process  which,  in  its  turn,  is  only  a  modification  of 
the  simple  operation.  The  sutio-es  being  tied,  the  cervix  hence- 
forward opens  into  the  bladder,  discharging  menstrual  blood 
into  its  cavity.  The  vagina  becomes  an  absolutely  blind  canal, 
cut  off  from  its  natural  communication  with  the  uterus  and 
its  abnormal  connection  with  the  cavity  of  the  bladder.  This 
operation  must  be  distinguished  from  colpocleisis  or  closure 
of   the  vagina,  presently  to  be  described. 

Urethral  or  XJrethro -Vaginal  Fistula. — In  this  form 
the  patient  can  often  exercise  more  or  less  control  over  the 
urine,  which,  however,  will  generally  escape  involuntarily  at 
times,  especially  during  sleep.  A  urethral  fistula  is  closed  by 
the  usual  paring  and  suturing  process.  It  must  be  repaired 
first  when  a  vesico-vaginal  fistula  also  exists.  The  catheter 
(Fig.  156)  must  be  introduced  before  the  paring  of  the  edges  of 
the  fistula  is  commenced.  Then  the  operation  is  performed,  as 
it  were,  upon  the  catheter,  which  must  be  retained  for  about 
seven  days  (see  notes  on  after-treatment  in  cases  of  the  opera- 
tion for  vesico-vaginal  fistula,  page  433).  In  one  case  where 
the  wall  of  the  urethi^a  had  been  torn  through.  Dr.  Boulton 
pared  the  edges  and  stitched  them  over  the  catheter,  which  was 
worn  for  a  month.  The  lu-ethra  healed  perfectly.  The  em- 
ployment of  this  catheter  obviated  frequent  catheterization,  or 
the  other  objectionable  alternative  of  draining  the  bladder 
through  an  artificial  vesico-vaginal  fistula. 

Atresia  of  Urethra  complicating  Vesico-Vaginal 
Fistula. — This  complication  must  be  remedied  before  the 
fistula  is  subjected  to  operation.  It  is  a  result  of  extensive 
damage  to  the  parts  involved,  and  general  sui'geons  must  bear 
in  mind  that  by  "  atresia  "  specialists  signify  a  far  more  com- 
plete obliteration  of  the  urethral  canal  than  is  observed  in  any 
form  of  stricture  of  the  male  urethra. 


438      OPERATIONS    FOR    RELIEF    OF    URINARY    FISTL'L^^,    ETC. 

Simon*  describes  a  case  of  atresia  of  the  iiretlii'a  between  a 
nretbi'o-vaginal  and  a  vesico-vaginal  fistula,  wbicli  he  cui'ed  by 
two  operations,  the  second  being  the  repair  of  the  latter  fistula, 
whilst  the  urethro-vaginal  fistula  and  the  lu-ethra  were  first 
repaired  by  a  very  ingenious  procedure,  which  will  now  be 
described. 

A  woman  had  been  subject  for  sixteen  years  to  incontinence 


■^  jjy 


Fig.  157. — Simox's  Case  of  Atresia  of  the  Ukethea  between  a  Ukethko- 
Vaginal  and  a  Large  Vesico-Vaginal  Fistula.     (See  text.) 

of  urine,  originating  from  injuries  during  labour.  Professor 
Simon  discovered  a  small  m^ethral  fistula,  and  a  very  wide 
communication  between  the  vagina  and  bladder.  In  Fig.  157, 
the  vestibule,  the  anterior  vaginal  wall,  and  the  os  uteri  are 
displayed.  The  meatus  is  seen,  and  just  above  it  (anatomically) 
the  tenacula  hold  up  portions  of  mucous  membrane ;  between 
these  portions  is  the  urethi'al  fistula.     Higher  up,  a  tenaculum 

*  Mittheilungen  aus  cler  CJdrurgischen  Klinik  dcf  Rostoclcer  KrankenJui uses 
wdhrend  cler  Jahre,  1861-65,  II.  Abtheiluiig,  p.  207,  and  Plates  III.  and  IV. 
Simon's  description  of  this  operation  has  been  repeatedly  quoted  by  other  ^\Tite^s, 
often  second-hand. 


RAKER    FORMS    OF    URINART    FISTULA. 


439 


is  seen  to  be  fixed  to  tlie  mucous  membrane  on  each  side  of  the 
vesico-vaginal  fistula,  which  is  very  large.  Immediately  above 
the  urethral  fistula,  the  urethra  and  a  small  portion  of  the 
bladder  close  to  the  vesical  end  of  that  canal  were  completely 
impervious,  and  were  represented  by  a  cicatricial  mass  firmly 
adherent   to   the   pubic  arch,  and  causing   a   deep   transverse 


Fig.  158.— Simon's  Case  of  Atkesia  of  the  Urethra  between  Two 

FiSTULiE. 

First  operation.     {See  text.) 

pucker    in    the    vaginal    mucous    membrane,    represented    in 
Fig.  157. 

The  first  operation,  for  the  closure  of  the  urethral  fistida  and 
the  formation  of  a  pervious  canal  for  the  imne,  is  explained  by 
Fig.  158.  The  anterior,  or  (anatomically)  lower  part  of  the 
fistula  was  pared,  together  with  a  considerable  portion  of  the 
vaginal  wall  on  each  side  of  it.  Then  the  part  of  the  wall  of 
the  bladder   and  the    adjacent   vaginal   wall   just   above   the 


440   OPERATIONS  FOR  RELIEF  OF  rRlXARY  FISTUL.^,  ETC. 

puckered  portion  adherent  to  the  puhes  were  set  free  and  pared, 
each  extremity  of  the  pared  portion  being  united  to  the  corre- 
sponding end  of  the  part  of  the  vagina  abeady  vivified.  An 
elliptical  wound  was  thus  formed ;  it  is  represented  in  Fig.  158, 
where  a  sound  is  seen,  passing  through  the  meatus,  and  behind 
the  wound,  till  its  end  appears  behind  the  vesico-vaginal  fistula. 
It  will  be  seen  that  the  transverse  pucker  of  the  vagina  now  Hes 
behind  the  wound,  the  sound  also  passing  in  front  of  it.  Ten 
sutui'es  were  then  passed,  as  in  the  ordinary"  operation  for  vesico- 
vaginal fistula,  so  as  to  bring  the  pared  and  raw  edges  of  the 
wound  together.  Thus,  as  may  be  understood  from  a  glance  at 
Fig.  158,  the  obliterated  part  of  the  urethra  and  bladder,  with 
the  cicatricial  mass  of  urethral,  vesical,  and  vaginal  tissues, 
were  bridged  over,  so  that  a  new  channel  was  formed  and 
the  vaginal  walls  were  closed,  by  the  sutures,  behind  that 
channel.  Four  weeks  later  the  vesico-vaginal  fistula  was  closed 
by  the  ordinary  operation.  The  cure  was  perfect,  no  inconti- 
nence of  urine  followed,  but  the  patient  had  to  pass  a  catheter, 
which  she  learnt  to  do  for  herself,  for  a  short  time,  as  the  cica- 
tricial tissue  lining  the  anterior  or  upper  wall  of  the  new 
channel  at  fii'st  caused  obstruction  to  voluntary  mictuiition. 

Vesico-Uterine  Fistula. — The  test  for  the  position  of  a 
urinary  fistula  has  been  already  given  at  page  422.  When 
the  milk  passes  through  the  os  uteri,  the  fistulous  communication 
will  be  between  the  uterus  and  the  bladder. 

When  the  fistula  is  evidently  in  the  eer\dx  near  the  os 
externum  the  case  is  complicated,  and  there  is  a  choice  of 
several  operations,  none  easy  of  performance.  The  best  plan, 
if  possible,  is  to  pass  a  director  up  to  the  uterine  orifice  of  the 
fistula  and  to  slit  up  the  anterior  lip  of  the  os  uteri,  making 
sure  that  the  fistula  is  reached.  The  edges  of  the  fistula  are 
vivified  and  sutures  are  passed  through  the  cervix  direct,  so  as 
to  bring  together  the  walls  of  the  cer%-ix  and  the  edges  of  the 
fistula  (Fig.  159). 

When  the  fistulous  passage  is  too  high  to  be  accessible  for  paring 
and  suturing,  the  edges  of  the  os  uteri  are  pared  and  united  by 
sutm'e.  The  uterus  henceforwards  discharges  menstrual  fluid 
through  the  fistula  into  the  bladder.  After  these  operations, 
where  the  bladder  is  made  the  receptacle  for  discharges  from 


RAKER    FORMS    OF    URINARY    FISTULA.  441 

the  uterus,  as  in  the  two  abeady  described  (pages  437,  440) 
and  in  closure  of  the  vagina,  it  has  been  observed  that  men- 
struation, often  scanty,  irregular,  or  suppressed  before,  as  is 
frequently  the  case  in  uiinary  fistulEe,  becomes  free  and  regular 
afterwards,  and  does  not  set  up  vesical  irritation. 


Fig.  159. — VesiCO-Utehine  Fistula. 

Anterior  lip  of  os  uteri  slit  up  to  fistula,  which  has  been  pared  ;  sutures  passed 
through  cervix  on  each  side  of  the  line  of  incision.     [Thomas.) 

Uretero-Vaginal  and  Uretero-XJterine  Fistula. — Dr. 

Parvin,  of  Philadelphia,  writes  in  the  sixth  volume  of  Ashhurst's 
International  Encyclopcadia  of  Surgery  : — "  In  1867  I  operated 
successfully  upon  a  uretero-vaginal  fistula  of  fourteen  years' 
duration,  by  making,  first,  a  vesico-vaginal  fistula,  cutting  from 
the  ureter  into  the  vagina,  then  after  a  few  days  denuding  a 
comparatively  large  surface  of  the  latter,  and  finally  inverting- 
that  surface  so  as  to  throw  the  ureteral  orifice  into  the  bladder. 
At  that  time  I  had  never  seen  any  report  of  a  similar  lesion, 
and  the  diagnosis  was  not  readily  made.  The  treatment  was 
still  more  difficult,  and  it  was  not  until  after  more  than  one 
failure  that  I  finally  succeeded." 

JJretero-  Uterine  Fistula. — The  test  for  this  condition  has  been 
described  at  page  422.  It  is,  fortunately,  verj'-  rare.  Inge- 
nious operations  have  been  practised,  with  more  or  less  success, 
by  different  operators,  but  no  two  cases  are  likely  to  resemble 
each  other  to  a  sufficient  extent  to  justify  a  strict  adhesion 
to  rules  which  may  have  been  observed  in  some  solitary  success- 
ful case,  nor  must  it  be  forgotten  that  we  do  not  always  hear  of 
failure.     Some  of  these  operations  are  described  in  Dr.  Graillard 


442       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULA,    ETC. 

Thomas's  Practical  Treatise  on  the  Diseases  of  Women.  Simon 
and  other  German  authorities  recommend  that  an  artificial 
vesico-vaginal  fistula  be  made,  and  that  the  vagina  be  closed, 
by  the  plastic  operation  presently  to  be  described,  below  that 
fistula.  This  appears  to  be  good  practical  advice,  for  a  uretero- 
uterine  fistula  entails  great  discomfort  from  incontinence  of  urine, 
and  this  is  relieved  by  closure  of  the  vagina ;  on  the  other 
hand,  cicatrization  around  the  seat  of  the  ureteric  fistula  may 
make  a  direct  operation  impossible,  even  to  the  most  expert. 

Other  Grerman  surgeons  and  specialists  have  thought  it  right 
to  remove  the  kidney  on  the  side  of  the  fistula.  One  case,  at 
least,  under  the  care  of  Professor  Zweifel,  recovered,  but 
surgery  of  this  kind  is  questionable. 

Closure  of  the  Vagina  by  a  Plastic  Operation, 
Kolpokleisis  or  Colpocleisis. — Some  of  the  forms  of 
urinary  fistula  above  described  cannot  be  closed  by  paring  of 
the  edges  and  uniting  of  the  raw  surfaces  by  means  of  sutures. 
The  surrounding  tissues  may  be  too  unhealthy  for  any  such 
operation  to  succeed,  the  fistula  may  be  inaccessible  for  any 
0]3erative  manipulation,  and  may  be  too  large  to  close.  In  these 
cases,  the  relations  of  neighbouring  parts  and  the  consistence 
of  their  tissues  are  so  altered  that  important  organs  might  be 
injured  by  the  knife. 

In  any  such  case,  it  is  often  best  to  pare  the  vaginal  walls, 
along  their  entire  circumference,  below  the  fistula,  and  well  in 
sight  of  the  operator,  and  to  pass  sutures  through  the  pared 
siu-faces,  so  that  when  they  are  tied  those  surfaces  are  brought 
together.  If  this  operation  should  succeed,  the  vagina  will  be 
completely  closed,*  and  the  part  above  the  line  of  adhesion  of 
the  pared  edges  will  form,  as  it  were,  a  portion  of  the  bladder. 
The  menstrual  blood  and  other  uterine  discharges  will  escape 
with  the  urine,  passing  out  of  the  cervix,  into  the  closed  part 
of  the  vagina,  and  thence  through  the  fistula  into  the  bladder 
and  out  of  the  lu-ethra. 

The  surgeon,  remembering  how  much  irritation  is  set  up,  as 

*  Complete  closure  of  the  labia  or  cpisiorrhapliy,  leaving  the  meatus  free,  lias 
been  attempted  for  cases  of  this  class,  but  the  anterior  part  of  the  pared  track 
often  remains  open,  so  that  urine  trickles  out  of  it  involuntarily,  and  the  object 
of  the  operation  is  totally  defeated. 


COLPOCLEISIS.  443 

a  rule,  by  urine  when  it  escapes  out  of  its  natural  channel  to  a 
part  of  the  organism  not  naturally  intended  to  receive  or 
transmit  it,  how  it  tends  to  putrefy  when  retained  in  an 
unnatural  pouch  or  cavity,  and  how  readily  solid  concretions 
form  on  any  rough  or  irregular  surface  in  the  bladder,  can 
hardly  look  on  this  operation  as  theoretically  sound.  Practice, 
however,  has  shown  that  the  expected  evils  just  noted  do  not 
necessarily  arise  after  plastic  closure  of  the  vagina.  Calculous 
concretions  do  not  appear  to  form,  and  the  urine  neither  stag- 
nates nor  causes  irritation.  It  is  certain  that  a  successful 
operation  of  this  class  is  far  more  satisfactory  than  a  partially 
successful  plastic  operation  performed  directly  on  the  vesico- 
vaginal fistula. 

There  are  two  grave  objections  to  plastic  operations  for 
closure  of  the  vagina.  In  the  first  place,  it  puts  an  end  to  the 
reproductive  function,  some  of  the  physiological  machinery  of 
which  may  still  remain  active  ;  indeed,  with  the  return  of 
comfort  and  good  health,  menstruation,  previously  suppressed, 
may  reappear  and  become  regular.  This  must  be  remembered, 
yet  in  most  cases  where  the  operation  is  needed,  the  morbid 
condition  has  completely  upset  the  functions  of  the  parts 
involved.  Secondly,  this  operation  may  be  almost  as  difficult, 
though  not  so  likely  to  prove  a  failure,  as  direct  closure  of  the 
fistula.  I  have,  indeed,  seen  the  vagina  successfully  sewn  up  in 
cases  where  the  operator  avowedly  closed  it  on  the  plea  that 
under  his  hands  the  more  direct  operation  would  less  probably 
succeed.  In  a  case  of  this  kind,  however,  the  vagina  must 
be  fairly  capacious  and  its  tissues  healthy  along  the  line  of 
operation.  Too  often  the  vagina  is  contracted  from  cicatri- 
zation, and  the  line  for  paring  will  pass  through  dense  cicatricial 
patches  and  areas  of  over-vascular  tissue  unhealthy  in  other 
respects.  The  vivifying  process  will  then  be  difficult  and  the 
chance  of  complete  union  uncertain.  Incomplete  union  means 
failure,  for  the  great  cause  of  discomfort  and  ill-health,  the 
incontinence  of  urine,  will  not  be  cured. 

The  Operation. — When  the  vagina  is  closed  for  the  relief  of 
urinary  fistula,  the  entire  circumference  a  little  below  the  lower 
border  of  the  fistula  must  be  pared,  just  as  the  entire  circum- 
ference of  the  fistula  itself  is  pared  in  the  direct  operation ; 


444   OPERATIONS  FOR  RELIEF  OF  URINARY  FISTVL.^,  ETC. 

and  the  sutures  are  introduced  in  tlie  same  manner.  In  Fig. 
160  the  process  is  explained.  A  sound  has  been  passed  into  the 
bladder  and  out  into  the  vagina  thi-ough  the  fistula.  In  the 
^'oodcut  it  is  seen  entering  the  meatus,  and  its  extremity  lies 
in  the  upper  part  of  the  vagina.     The  entire  circumference  o£ 


Fig.  160. — CoLi'OCi.Eisis, 

Showing  the  entire  circumference  of  the  vaginal  mucous  membrane  pared,  and 
the  sutures  introduced.      (Sivion.) 


the  vagina  has  been  pared,  below  the  fistula  which  is  not  seen 
in  the  drawing.  Sutm-es  have  been  passed  through  the  opposite 
sides  of  the  pared  area,  emerging  through  the  mucous  mem- 
brane at  the  anterior  and  posterior  borders  of  the  lower  limit 
of  that  area.     The  vulva  is  held  aj^art  by  flat  retractors. 


COLPOCLEISIS.  445 

Precise  rules  cannot  be  given,  as  the  operation  varies  in  every 
case.  Lithotomy  position  is  probably  the  best,  and  retractors 
may  answer  better  in  some  cases  than  Sims'  speculum  intro- 
duced as  in  the  operation  for  vesico-vaginal  fistula.  The 
vaginal  mucous  membrane  should  be  seized  with  spring-forceps 
and  a  vesico-vaginal  fistula  knife  passed  completely  round  ;  thus 
will  be  formed  the  lower  border  of  the  area  about  to  be  pared. 
The  mucous  membrane  is  then  dissected  up  to  the  extent  of  a 
little  over  a  quarter  of  an  inch ;  care  must  be  taken  to  make  the 
upper  border  even.  Free  cleansing  with  small  mounted  sponges 
will  be  needed  throughout  this  process.  The  sutures,  of  silk- 
worm-gut or  silver  wire,  may  be  passed  by  means  of  a  handled- 
needle  eyed  near  the  point  and  well  curved.  A  catheter  should 
be  retained  in  the  bladder  after  the  sutures  are  tied,  and  the 
bladder  is  then  injected  with  warm  water,  so  that  the  surgeon 
may  ascertain  if  the  closure  of  the  vagina  be  complete.  The 
urine  should  be  regularly  drawn  off,  and  the  sutures  may  be 
removed  about  the  tenth  day. 

This  operation  was  performed  successfully  by  Dr.  Bantock 
in  the  case  described  in  the  introductory  observations  on  vesico- 
vaginal fistula  (page  418).  The  vagina  was  found  to  end  in  a 
blind  extremity  about  two  and  a  half  inches  from  the  vulva. 
The  fistula  had  contracted,  dming  the  twelve  months,  to  an 
opening  about  a  quarter  of  an  inch  in  diameter,  through  which 
a  small  portion  of  the  wall  of  the  bladder  protruded.  The 
uterus  could  not  be  reached  ;  it  could,  however,  be  felt  by  recto- 
bimanual  palpation,  and  appeared  to  be  very  small  in  size.  The 
precise  relations  of  the  cervix,  the  bladder,  and  the  vagina  above 
the  seat  of  atresia  could  not  be  made  out.  It  did  not  seem 
advisable  to  attempt  to  open  up  the  cicatricial  tissue,  as  the 
relations  of  important  parts  were  so  much  disturbed,  and  there- 
fore the  only  operation  likely  to  afford  relief  was  closiu-e  of  the 
vagina.     The  patient  had  not  menstruated  since  her  pregnancy. 

The  mucous  membrane  of  the  vagina  below  the  fistula  and 
the  corresponding  part  of  the  posterior  vaginal  wall  were  dissected 
up  partly  by  scissors  and  partly  by  dissection,  to  the  extent  of 
about  half  an  inch.  This  proceeding  was  difiicult  owing  to  the 
diseased  state  of  the  tissues,  but  when  six  silkworm-gut  sutirres 
had  been  introduced  (see  Fig.  160),  by  means  of  a  tubular  needle 


446      OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULiE,    ETC. 

(No.  3  size),  the  raw  surfaces  were  readily  approximated,  for 
owing  to  tlie  narrowness  of  the  vagina  they  were  not  far  apart. 
Thus,  in  this  x^articular  case  a  segment  of  vagina,  cutoff  from  the 
uterus  by  the  cicatricial  atresia  and  from  the  vulva  by  the  sutm-ed 
operation-wound,  was  left  in  communication  with  the  bladder. 
A  catheter  was  passed  into  the  bladder  and  made  fast  to  the 
pudendal  hairs,  and  a  long  piece  of  elastic  tubing  conveyed  the 
urine  into  a  bottle  by  the  side  of  the  bed,  containing  a  1  in  10 
solution  of  sulphurous  acid.  This  operation  was  performed 
on  June  11th,  1880.  The  catheter  was  changed  on  June  13th 
and  15th ;  on  the  16th  it  was  removed  altogether  and  passed 
occasionally.  On  June  20th  the  sutm-es  were  removed,  and  the 
parts  were  found  well  united.  The  patient  was  sent  to  a  nm'sing 
home,  whence  she  was  discharged  in  a  few  weeks  with  perfect 
control  over  the  bladder. 

Faecal  Fistula— Recto-Vaginal  Fistula.— This  con- 
dition is  generally  the  result  of  cancer  of  adjacent  organs.  It 
occasionally  occurs  in  syphilitic  patients,  especially  in  con- 
nection with  stricture  low  dovna.  in  the  rectum.  Recto-vaginal 
fistula  may  follow  woimds  of  the  recto-vaginal  septum ;  such 
wounds  may  be  received  accidentally,  as  when  the  patient  falls 
on  the  end  of  a  sharp  or  blunt  object  which  can  penetrate  the 
body  sufficiently  far  to  damage  the  pudenda.  An  accident  of  this 
kind  is  not  rare  late  in  childhood.  Thus,  a  schoolgiii  may  fall, 
dm-ing  play,  astride  upon  a  spiked  rail-post,  or  on  a  stick  or 
umbrella  ;  or,  as  in  a  case  which  I  once  saw  in  a  general  hosiDital, 
a  slate-pencil  may  cause  the  wound.  The  injury  may  also  be 
caused  by  felonious  attempts  at  abortion,  and  by  foreign  bodies 
introduced  for  various  other  objectionable  reasons.  Specimen 
4,673  in  the  pathological  collection  of  the  Royal  College  of 
Surgeons  shows  a  large  laceration  of  the  posterior  vaginal  fornix, 
opening  not  into  the  rectum  but  into  the  peritoneum.  The  patient, 
a  woman  aged  thirty,  had  herself  caused  the  in  j  my  by  introducing 
a  candle  into  the  vagina,  and  death  ensued  in  a  few  days.  This 
shows  that  not  very  great  force  is  required  to  ruptm'e  the 
posterior  vaginal  wall.  It  has  even  been  torn  in  coitus,  in  old 
subjects.  Lastly,  after  the  surgical  repair  of  ruptured  perineum, 
the  upper  part  of  the  opposed  surfaces  may  fail  to  unite.  The 
surgeon  who  is  acquainted  with  the  pathology  of  the  healing  of 


RECTO-VAGINAL    FISTULA.  447 

wounds,  and  the  results  of  neglecting  such  injuries,  can  under- 
stand how  often  wounds  in  the  recto-vaginal  septum  may  result 
in  fistula.  Ulceration,  through  the  pressure  of  a  hadly-fitting 
or  a  broken  pessary,  may  cause  a  wound  which  is  practically  a 
fistula  from  the  first. 

Abscesses  in  the  recto- vaginal  septum,  from  any  cause  what- 
ever, may  produce  a  fistula.  In  labour,  injuries  to  the  septum  of 
a  kind  likely  to  be  followed  by  recto-vaginal  fistula  are  rare  ; 
but  the  condition  may  be  caused  by  complications  dming  the 
puerperium,  as  pelvic  cellulitis  with  suppuration,  or  diphtheritic 
vaginitis  (Schroder) . 

Symptoms. — A.  recto- vaginal  fistula,  when  small,  may  cause 
very  little  inconvenience,  but  when  large  enough  to  allow  of  the 
involuntary  escape  of  flatus  and  fseces  it  is  certain  to  keep  the 
patient  in  a  miserable  condition  until  it  is  repaired.  The  patient 
applies  for  relief  from  the  distressing  symj)toms  just  noted,  and 
then  the  fistula  may  generally  be  detected  by  touch,  or  by  careful 
exploration  of  the  posterior  vaginal  wall,  as  the  patient  lies  on 
her  back  in  a  good  light.  A  Sims'  speculum  is  introduced  and 
passed  along  the  anterior  vaginal  wall,  then  the  posterior  wall  is 
carefully  examined.  The  surgeon  must  remember  that  the 
vaginal  mucous  membrane  does  not  bear  handling  with  the 
volsella,  being  far  more  sensitive  than  the  cervix  uteri.  The 
forefinger  will  answer  the  purpose  of  pressing  down  and  pushing 
aside  any  part  of  the  posterior  wall.  When  there  is  some 
difiiculty  in  finding  the  fistula,  milk  and  water,  or  water  stained 
with  decoction  of  logwood  or  cochineal,  may  be  injected  into  the 
rectmn,  as  in  a  similar  kind  of  test  for  vesico-vaginal  fistula. 

Operation. — A  plastic  operation  for  the  repair  of  a  recto- 
vaginal fistula  will  always  be  needed,  excepting  in  cases  of 
cancer,  or  of  syphilitic  disease  of  the  rectum.*  The  operation 
must  be  conducted  on  the  same  principles  as  when  a  vesico- 
vaginal fistida  is  cured.  The  bowels  must  first  be  thoroughly 
cleared  out  by  an  aperient,  administered  about  forty-eight  hours 
before  operation,  followed  by  an  enema  to  be  thi'own  up  an 
hour  or  two  before  the  patient  is  placed  on  the  operating  table. 
When  the  fistula  is  very  low  down,  it  is  best  to  divide  the 

*  When  complicated  by  stricture  of  tlie  rectum  tlie  latter,  the  primary  con- 
dition, must  be  cured  first. 


448   OPERATIONS  FOR  RELIEF  OF  URINARY  FISTULA.,  ETC. 

perineum  in  the  middle  line,  as  far  as  the  fistula,  the  edges  of 
which  are  pared ;  the  parts  are  then  reunited  by  the  ordinary 
operation  for  the  repair  of  a  completely  ruptured  perineum. 

Should  the  fistula  be  higher,  the  patient  must  be  placed  in 
lithotomy  position,  the  labia  held  well  apart  by  assistants,  and 
a  Sims'  speculum  passed  along  the  anterior  vaginal  wall.  The 
late  Dr.  Thorburn  considered  that  using  Sims'  speculum  thus 
*'  is  certainly  not  in  accordance  with  the  principles  upon  which 
the  use  of  that  instrument  is  based,"  nevertheless  it  thi'ows  a 
good  Kght  on  the  posterior  vaginal  wall. 

That  part  of  the  vagina  being  exposed,  the  operator  must 
ascertain  how  he  may  keep  the  fistula  well  in  sight  and  ■\\'ithin 
reach  during  the  paring  of  its  edges.  The  sphincter  ani 
should  first  be  well  stretched  by  the  forefingers.  Then  the 
fistula  is  best  supported  by  a  large  rectal  bougie  passed  thi'ough 
the  anus.  The  vaginal  mucous  membrane  should  be  pared 
freely.  The  operator  should  bear  in  mind,  as  Dr.  Thorburn 
has  noted,  that  the  bevelling  of  the  edges  is  often  abeady  very 
great  before  any  paring  is  done,  as  the  fistula  is  widest  on  the 
vaginal  side.  The  edges  of  the  fistula  being  thoroughly  pared, 
and  heemorrhage  checked,  the  sutures  are  applied  as  in  the 
operation  for  vesico-vaginal  fistula.  A  rectal  tube  should  be 
retained  after  the  operation.  The  rules  for  after-treatment  will 
be  the  same  as  in  repair  of  the  perinemu,  the  chief  trouble 
arising  not  from  the  bladder  and  the  catheter,  as  after  the 
operation  for  vesico-vaginal  fistula,  but  rather  fi'om  uncertainty 
in  relation  to  the  choice  of  a  proper  time  for  opening  the  bowels 
and  for  removing  the  sutures.  Some  operators  close  the  fistula 
from  the  rectal  surface. 

Entero-Vaginal  Fistula. — A  communication  between  the 
intestine  above  the  rectum  and  the  vagina  is  rare,  and  is 
generally  associated  with  conditions  which  render  an  operation 
unadvisable.     The  fistula  is,  in  fact,  an  artificial  anus. 

Epispadias. — This  malformation  is  rare  in  the  female. 
Dr.  Dohrn*  has  recently  described  a  distinct  case  of  this 
deformity,  unaccompanied  by  ectopia  vesicae,  in  an  adult  female. 
In  epispadias  the  external  organs  are   generally  more  or  less 

*  Zeitschrift  fur  Geburtshillfc  und  Gyniikulocjie,  Band  xii.,  Heft  1,  1886. 


EPISPADIAS ECTOPIA    VESICyE.  449 

-imperfectly  developed.  The  clitoris  may  be  simply  notched,  or 
deeply  cleft,  or  completely  divided  into  two  halves,  lying  wide 
apart.  In  addition,  the  anterior  wall  of  the  urethra  may  be 
defective,  so  that  that  canal  may  appear  as  a  wide  funnel- 
shaped  depression,  with  an  orifice,  at  the  bottom  of  the- funnel, 
surrounded  by  a  weak  sphincter.  The  finger  can  readily  be 
introduced  into  the  orifice,  and  then  will  be  found  to  enter  the 
bladder  immediately.  Sometimes  the  mucous  membrane  of  the 
open  urethra  bulges  and  presents  an  appearance  puzzling  to  the 
observer.  The  condition  of  the  clitoris  will  explain  the  anomaly. 
More  or  less  incontinence  of  urine  is  certain  to  exist  when  the 
urethra  is  thus  deficient. 

Operative  interference  is  hardly  necessary  in  cases  of  bifid  or 
completely  split  clitoris,  yet  when  such  a  deformity  exists,  the 
urethra  must  be  examined.  When  epispadias  involves  the 
urethra,  causing  incontinence  of  urine,  a  plastic  operation  will 
be  required.  The  inner  sides  of  the  divided  clitoris  and  its 
prepuce  must  be  denuded  of  their  integument,  and  those 
structures  can  then  be  sewn  together.  They  will  then  lie  in 
front  of  the  to-ethra,  which  will  be  restored  to  its  natural 
position. 

Ectopia  Vesicae.  —  In  this  malformation  the  anterior 
wall  of  the  bladder  and  urethra  is  deficient.  Mr.  John 
Wood  insists  upon  the  necessary  existence  of  epispadias  in 
cases  of  ectopia  of  the  bladder,  though,  as  is  well  known, 
epispadias  does  not  necessarily  involve  ectopia.  In  female 
still-born  children,  or  female  infants  who  survive  their  birth 
but  a  few  days  or  hours,  ectopia  vesicae  is  not  very  rare.  It  is 
certain  that  in  females  it  is  often  associated  with  other  mal- 
formations of  a  yet  more  serious  character,  whilst  in  males 
ectopia  vesicae  frequently  exists  as  a  distinct  disease,  thoroughly 
deserving  that  term  in  its  etymological  sense  dis  ease,  yet 
unaccompanied  by  any  other  deformity.  Mr.  Wood  gives  the 
proportion  of  female  cases  to  males  as  one  in  ten. 

The  scientific  aspects  of  ectopia  cannot  be  considered  in  these 
pages.  The  sui'geon  who  contemplates  operation  on  a  very 
young  subject  should  study  Dr.  Champneys'  valuable  essay  on 
"Extroversion  of  the  Bladder,"  in  the  thirteenth  volume  of 
the  *SY.  Bartholomew'' s  Hospital  Reports,  where  a  complete  sum- 

G    G 


450   OPERATIONS  FOR  RELIEF  OF  TRIXARY  FISTUL.F:,  ETC. 

maiy  of  oases  will  be  found.  Although  most  female  childi-en 
with  ectopia  vesic£e  die  from  other  malformations  incompatible 
with  life,  yet  some  live  to  adult  age  and  have  even  married  and 
borne  chilcli-en.  Some  cases  have  passed  through  life  as  reputed 
hermaphrodites.  This  error  is,  however,  most  likely  to  occur 
when  the  patient  is  a  male. 

The  appearances  of  the  affected  parts  in  a  case  of  ectopia 
vesicae  are  characteristic.  The  oj)en  bladder  forms  a  red  project- 
ing mass  in  the  hypogastrium.  The  orifices  of  the  ureters  can 
generally  be  seen  without  difficulty.  The  symphysis  pubis  is 
usually  imperfect — indeed,  the  pubic  bones  lie  often  three 
or  four  inches  apart  at  the  middle  line,  and  are  otherwise  abnor- 
mally developed.  This  malformation  of  the  pehas  affects  the 
patient's  gait.  It  is  needless  to  describe  the  loathsome  incon- 
veniences which  arise  from  the  deformity  of  the  bladder. 

The  first  thing  to  be  done  when  a  case  of  ectopia  vesicae  is 
examined  is  to  ascertain  for  certain  the  sex  of  the  patient. 
This  is  a  self-evident  proposition,  but  not  always  easy  of 
solution.  Hermaphroditic  malformations  may  exist  in  a  case 
of  this  infirmity.  The  surgeon  must  remember  that  the 
testicles  maybe  arrested  in  their  descent, and  that  an  involution 
■of  the  integument  resembling  a  vagina  has  been  observed  in 
males.  The  rectum  must  be  cleared  of  scybala  before  examina- 
tion, since  fsecal  masses  may  lead  to  grave  errors  during  vaginal 
exploration.  The  anus  is  often  placed  abnormally  forward  and 
the  perineum  is  short. 

Various  operations  have  been  de^'ised  for  the  rehef  of  ectopia 
vesicae.  They  are  based  upon  one  of  two  principles.  The 
first  principle  is  the  diversion  of  the  stream  of  urine  into  the 
rectmn.  The  second  is  the  closing  in  of  the  bladder  by  making 
for  it  an  anterior  wall  out  of  the  abdominal  integuments.  This 
is  done  in  the  course  of  operations  performed  on  the  first  princi- 
ple, but  only  as  a  more  or  less  secondary  measm-e.  The 
second  principle  can  and  has  been  followed  without  the 
manufacture  of  a  fistulous  communication  with  the  rectum. 

Operations  performed  upon  the  first  luinciple  are  open  to 
numerous  objections.  They  are  based  upon  two  false  theories. 
Firstly,  they  professedly  imitate  the  cloaca  or  common  excretory 
canal  of  the  monotrematous  mammals,  and  the  lower  vertebrata. 


OPERATION    FOR    ECTOPIA    VESICJE.  451 

Secondly,  they  are  supposed  to  take  away  one  cause  of  irritation 
without  substituting  another. 

The  morphological  theory  is  thoroughly  unsound.  The 
cloaca  of  an  Ornithorhynchus,  or  bird,  is  meant  and  made  to 
transmit  urine  and  faeces  without  irritation.  The  rectum  in 
man  is  not  so  constructed.  Hence  it  is  not  advisable  to  make 
a  man  or  woman  monotrematous.  The  attempt  may  entirely 
fail,  and  the  urine  may  escape  into  the  peritoneum  or  pelvic 
connective  tissue.  When,  on  the  other  hand,  the  operation 
succeeds,  the  anatomical  cloaca  thus  formed  may  be  a  triumph 
of  sm-gical  skill,  but  it  will  never  act  to  physiological  perfection. 
A  natural  cloaca,  of  course,  allows  of  evacuation  of  excreta  in 
complete  comfort.  This  artificial  cloaca  involves  great  irrita- 
tion and  perhaps  ultimately  fatal  results. 

In  these  operations,  either  the  ureters  are  separated  from  the 
bladder  and  fastened  to  a  wound  in  the  rectum,  or  a  communi- 
cation with  that  part  of  the  alimentary  canal  is  made  by  means 
of  an  incision  through  the  base  of  the  bladder.  The  front  of 
the  bladder  is  then  closed  in. 

Far  better  results  have  followed  the  class  of  operation  based 
on  the  second  principle,  namel\%  the  simply  covering-in  of  the 
bladder.  Pancoast,  Timothy  Holmes,  and  John  Wood  have 
caused  these  operations  to  be  admitted  into  the  ranks  of 
established  and  legitimate  surgical  pi'ocedures. 

In  the  operation  for  closing  in  the  walls  of  the  bladder,  as 
performed  by  Wood  and  Mayo  Robson,  a  flap  of  integument  is 
cut  from  the  abdominal  wall  above  the  bladder,  the  cutaneous 
surface  of  the  flap  is  turned  against  the  bladder,  and  two  lateral 
flaps  are  made  and  fastened  with  their  raw  surfaces  touching 
the  raw  surface  of  the  first  flap.  Thus  the  anterior  wall  of  the 
bladder  after  operation  is  cutaneous.  Experience  has  showoi 
that  the  hairs  on  the  cutaneous  surface  give  trouble  at  first,  but 
the  bulbs  are  ultimately  destroyed  by  the  action  of  the  urine. 
It  has  also  been  discovered  that  this  cutaneous  surface  becomes 
converted  into  mucous  membrane,  just  as  the  reverse  change 
occurs  in  prolapse  of  the  vagina. 

The  Operation. — The  parts  should  be  prepared  on  the 
excellent    principles   advocated  by   Mr.    John    Wood.*      The 

*  Heath's  Dictionary  of  Practical  Surgery,  article  "Ectopia  Vesicfe." 


452       OPERATIOXS    FOR    RELIEF    OF    IRIXARY    FISTULA,    ETC. 

hypogastrium  and  genitals,  and  the  abdominal  integuments  above 
the  bladder,  are  first  well  shaved.  A  depilatory  should  be  used 
for  the  integument  over  the  site  of  the  future  anterior  flap.  A 
drop  of  strong  nitric  acid  should  be  applied  to  the  several  groups 
of  hairs  on  the  integument  at  intervals.  During  the  applica- 
tion of  the  acid,  the  bladder  and  the  adjacent  parts  must  be 


Fig.  161. — AVuod's  Oi-euatiox  for  the  Crr.E  of  Ectopia  Vesica. 
1.  The  flaps  marked  out.     {Mayo  Eobson.) 

protected  by  a  thick  layer  of  olive  oil  and  chalk.  When  the  skin 
has  healed  it  must  be  washed  before  operation,  Avith  a  carbolized 
solution.     The  strength  which  Mr.  "Wood  uses  is  2|  per  cent. 

When  the  patient  is  under  chloroform  and  laid  on  her  back, 
the  outline  of  the  flaps  should  be  marked  "s^^th  pen  and  ink. 
The  vertical,  upper  or  umbilical  flap  (Fig  161)  is  marked 
out  by  a  pair  of  parallel  lines  running  along  tlie  sides  of  the 


OPERATION    FOR    ECTOPIA    VESICA.  453 

bladder  upwards.  Tliey  must  extend  beyond  tlie  upper  limit 
of  tbe  bladder  a  little  farther  than  the  distance  between  that 
point  and  the  umbilicus.  This  rule  is  far  more  important 
when  the  operation  is  being  performed  on  a  female  subject, 
than  when  the  patient  is  a  male.  Above,  the  lines  are  united 
by  a  curve  with  its  convexity  upwards.  The  lateral  or  groin 
flaps  are  to  be  marked  out  each  as  a  pyriform  surface  of 
integument  with  the  outer  extremities  broad  and  well  rounded 
(Fig.  161).  The  upper  border  must  be  prolonged  inward  on 
the  labium  as  far  as  the  site  of  the  normal  urethra.  When 
complete,  the  vertical  line  representing  one  border  of  the 
vertical  flap  should  bisect  it.  The  lower  border  need  not 
extend  quite  so  far  inwards.  These  flaps  must  be  long 
enough  to  meet  in  the  middle  line  when  folded  inwards. 

The  knife  is  now  carried  along  the  lines  marked  for  the 
vertical  flap,  which  is  then  carefully  dissected  downwards.  The 
flap  should  be  gently  held  by  the  operator's  left  thimib  and 
finger.  Surgeons  accustomed  to  abdominal  section,  where 
pressure-forceps  are  used  lavishly  and  without  injurious 
results,  must  remember  that  long  skin-flaps  will  not  tolerate 
these  instruments,  so  it  is  best  to  twist  bleeding  vessels  at 
once.  As  the  vertical  flap  is  being  dissected  downwards,  Mr. 
Wood's  caution  must  be  borne  in  mind — that  is  to  say,  care 
must  be  taken  not  to  cut  the  flap  too  thin.  This  accident  is 
most  likely  to  occur  close  above  the  upper  limits  of  the 
bladder,  where  the  subcutaneous  tissue  is  scanty  or  absent, 
and  the  aponeuroses  around  the  tense  linea  alba  thin  and 
easily  wounded.  Hence  the  operator  must  dissect  slowly,  and 
look  where  he  is  cutting,  lest  he  should  cut  the  flap  too  thin 
and  run  the  risk  of  a  slough,  or  too  thick  so  as  to  cut  into 
the  peritoneum  or  subserous  cellular  tissue.  This  latter  acci- 
dent may  entail  fatal  extravasation  of  urine. 

The  lateral  flaps  are  then  dissected  up.  The  external  pudic 
vessels  are  divided  in  the  course  of  the  dissection,  and  sometimes 
require  ligature.  All  the  flaps  are  then  folded  back,  bleeding 
allowed  to  cease,  and  the  exposed  raw  siu'faces  cleaned  so  as  to 
be  free  from  clots.  Mr.  Wood  employs  a  spray  of  a  saturated 
solution  of  boracic  acid.  The  raw  siu-faces  should  be  allowed 
time  enough  to  become  glazed. 


454       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTULiE,    ETC. 

The  vertical  flap  is  now  tm-ned  downwards,  and  Mr.  Wood 
unites  eacli  of  its  corners  to  the  cut  edge  of  integamient  on  each 
side  of  the  site  of  the  urethra,  hy  wire  or  silkworm-gut  sutui-es. 
The  lateral  flaps  are  then  folded  over  the  vertical  flap.  The 
latter  now  lies  with  its  raw  surface  forward,  so  by  bending 
the  lateral  flaps  inwards  their  raw  surfaces  will  touch  that  of 
the  vertical   flap.      The   inner  edges  of  the   lateral  flaps   are 


-u. 


/ 


X/ 


-He 


Fig.  162. — "Wood's  Opeuatiox  for  the  Cuke  of  Ectopia  YEsiciE. 

2.  The  lateral  flaps  stitched  over  the  vertical  flap.     The  gaps  left  behiiid  the 
three  flaps  covered  in  by  suture  of  the  integument.      [Mmjo  liobson.) 


united  across  the  middle  line  by  a  few  closely-apphed  wire 
or  silkworm-gut  sutures  (Fig.  162).  The  raw  surface,  on  the 
abdomen  above  the  bladder,  whence  the  vertical  flap  was 
dissected,  is  covered  by  ch-awing  the  cut  edges  of  integument 
together  and  holding  them  in  place  by  means  of  sutui'es. 
This  manoeu%Te  not  only  closes  in  the   exposed   surface,  but 


OPERATION    FOR    ECTOPIA    VESICA. 


455 


also  takes  the  strain  off  the  reflected  flaps.  The  edges  of  the 
gap  formed  by  the  displacement  of  the  lateral  flaps  must  be 
united  in  the  same  way  (Fig.  162). 

Mr.  Wood  rightly  warns  operators  against  a  danger  which 
is  not  encountered  in  plastic  operations  on  the  face  or  perineum. 
Sudden  movements  of  the  abdominal  walls,  from  coughing  or 


Fig.  163. — Ectopia  Vesicae  after  Opkration. 

Retraction  of  lateral  flaps,  lower  part  of  vertical  flap  exposed  and  drawn 
upwards,  bladder  uncovered  below.  Cicatricial  tissue  along  line  of  flaps  above. 
New  flaps  indicated  by  dotted  lines.      [Mayo  Eohson.) 

straining,  may  cause  a  penetrating  wound  from  the  knife,  which 
instrument  may  also  cut  the  suddenly  protruded  bladder. 
Moreover,  such  movements  are  very  troublesome  when  the 
flaps  are  being  dissected. 


456       OPERATIONS    FOR    RELIEF    OF    URINARY    FISTUL.T.,    ETC. 

I  have  abeacly  observed  that  the  vei-tieal  flap  must  he  cut 
long  and  broad.  Care  must  also  be  taken  that  the  lateral 
flaps  be  not  too  narrow.  I  have  been  describing  the  operation 
as  performed  on  the  female  only,  so  that  by  "  long  and  broad  " 
and  "  too  narrow,"  I  signify  longer  and  broader  than,  and  as 
narrow  as,  when  the  operation  is  perfoinned  on  the  male,  as 
described  in  most  text-books. 


Fig.  164. — Ectopia  Vesice,  Secoxdaky  Operation. 
New  flaps  (see  preceding  ligiuc)  uuited  and  healed.     (Mayo  Robson. ) 

Still,  notwithstanding  the  greatest  care  in  making  the  flaps 
as  wide  as  possible,  experienced  operators  have  met  with 
unsatisfactory  results.  In  the  process  of  healing,  the  side 
flaps  have  been  known  to  retract  to  such  an  extent  as  to  draw 
upwards  the  lower  margin  of  the  vertical  flap,  exposing  a 
portion  of  its  cutaneous  surface  and  lapng  bare  the  lower  part 
of  the  bladder  (Fig.  163).     In  such  a  case  Mr.  Mayo  Eobson's 


OPERATION-    FOR    ECTOPIA    VESICA.  457 

operation  will  be  necessary.*  THe  prominent  folds  of  integu- 
ment forming  the  labia  majora  are  incised  for  about  three 
inches  vertically.  From  the  upper  end  of  each  incision, 
another  is  carried  outwards  (Fig.  163).  In  this  manner  two 
triangular  flaps  of  skin  are  formed  and  dissected  up.  The 
everted  lower  portion  of  the  old  vertical  flap  (which  in  Fig.  163 
appears  as  the  triangular  surface  above  the  exposed  part  of  the 
bladder)  is  dissected  downwards,  so  that  its  cutaneous  surface 
once  more  covers  the  bladder.  Then,  the  triangular  flaps  are 
slid  over  the  replaced  portion  of  the  vertical  flap.  Their  raw 
surfaces  are  thus  brought  into  apposition.  The  inner  margins 
of  the  triangular  flaps  are  united  by  sutures,  and  their  upper 
margins  similarly  united  to  the  cut  lower  surfaces  of  the  old 
lateral  flaps,  thus  refreshed  in  the  process  of  detacliment  of  the 
everted  vertical  flap.  Fig.  163  will  explain  these  manipu- 
lations better  than  any  written  description.  When  healed  the 
parts  will  appear  as  in  Fig.  164. 

After  the  operation  for  ectopia,  the  wounds  should  be  painted 
over  with  collodion.  The  patient  is  then  placed  in  bed,  on  a 
waterproof  sheeting.  Her  knees  must  then  be  carefully  fixed 
in  a  flexed  position  by  a  bandage  holding  them  together  and 
approximating  them  to  the  shoulders,  which  must  be  well  sup- 
ported by  pillows.  High  temperatures  are  sometimes  observed 
shortly  after  the  operation.  An  india-rubber  drainage-tube 
must  be  inserted  into  the  vagina,  and  cleaned  and  replaced  daily. 
A  cradle  is  then  placed  over  the  patient's  body.  Irrigation 
with  a  half-saturated  solution  of  boracic  acid  lotion  is  advisable 
if  the  flaps  become  swollen  and  inflamed. 

Mr.  Wood  recommends  that  the  sutures  be  left  alone  till 
they  have  become  useless.  Then,  about  the  end  of  a  fortnight, 
the  patient  may  be  put  under  chloroform,  and  all  the  sutures 
that  have  not  dropped  off  may  be  removed. 

*  "Extroversion  of  Bladder"  {British  Jlcdical  Journal,  vol.  i.  1885,  p.  222). 


458 


CHAPTER  XVII. 

OPERATIOXS   OX   THE   VAGIXA,    VULVAR   STRUCTURES,   AX'D 
URETHRA. 

Congenital  Atresia  of  the  Hymen  and  Vagina. — 

By  this  term  I  include  the  affection  rightly  or  wrongly  de- 
scribed as  "imperforate  hymen"  in  most  text-books,  together 
Tvith  cases  of  closure  of  the  lower  part  of  the  vagina  without 
an}^  further  deficiency  of  the  genital  canal.  The  symptoms 
will  be  retention  of  menses  or  heematocolpos,  causing  serious 
changes  in  the  more  important  organs  higher  up.  In  the  first 
chapter  of  this  manual  I  dwelt  at  length  on  the  varieties  of  the  - 
hymen,  some  of  which  are  occasionally  mistaken  for  morbid 
conditions,  especially  in  infancy.  A  correct  knowledge  of  the 
anatomy  of  the  vulva  and  of  the  more  frequent  malformations 
of  the  vagina  is  absolutely  necessary  for  the  surgeon  who 
proposes  to  operate  for  the  relief  of  atresia. 

Atresia  in  Infancy  and  Childhood. — The  surgeon 
must  not  mistake  natui^al  or  other  appearances  for  imperforate 
h}Tnen,  when  examining  an  infant.  The  labia  often  adhere. 
The  inner  surfaces  of  the  natm-al  labieform  h}Tnen  of  infants 
(page  5,  Fig.  3,  I.),  frequently  stick  together.  A  linguLiform 
hymen  (page  5,  Fig.  3,  II.)  may  also  have  adherent  edges. 
Its  unusual  appearance  gives  the  observer  the  idea  that  disease 
or  malformation  must  exist,  and  the  morbid  condition  with 
which  the  hymen  is  generally  associated  is  want  of  patency. 
Hence  this  kind  of  adhesion,  produced  by  tenacious  mucus 
between  the  apposed  surfaces,  is  often  mistaken  for  "  imperforate 
hymen,"  and  so  described  in  text-books.  Forcible  traction  on 
the  two  halves  of  the  hymen  separates  them  at  once ;  sometimes 
a  little  bleeding  follows,  just  as  occurs  at  the  angles  of  the 


ATRESIA    VAGIX^.  459 

mouth  when  the  lips  are  sore.  The  surgeon  instinctively  believes 
that  he  has  torn  tlirough  an  imperforate  hymen,  when  he  has 
simply  parted  the  two  halves  of  a  natural  infantile  hymen. 
The  cause  of  this  false  imperforate  hymen  is  want  of  cleanli- 
ness, or  mild  vaginal  catarrh.  In  the  more  acute  catarrh,  so 
common  in  strumous  children,  the  edges  of  the  hymen  often 
hecome  thickened.  It  is  probably  through  this  disease  that 
some  of  the  peculiar  forms  of  hymen  ah-eady  described  (page 
6)  are  developed. 

Before  puberty  atresia  generally  produces  no  symptoms. 
Mucus  rarely  accumulates,  as  menstrual  blood  does  later  on. 
Matthews  Duncan  believes  that  the  mucus  is  reabsorbed  ;  Dohrn 
considers  that  the  vagina  secretes  little  or  none  of  that 
substance  under  the  circumstances.  We  do  not  hear  of  atresia 
with  vaginitis  and  retention  of  discharge  in  children.  Tet 
cases  of  accumulation  of  mucus  are  said  to  have  occurred. 
As  Mr.  Owen  rightly  recommends,*  when  an  obstruction  is  torn 
open  in  the  way  above  described,  a  small  piece  of  cotton-wool, 
covered  with  vaseline,  may  be  placed  between  the  edges  of 
the  linear  wound  for  a  few  days.  This  may  be  done  even 
when  it  is  evident,  as  is  almost  invariably  the  case,  that 
the  edges  of  a  normal  labieform  hymen  have  simply  been 
pulled  apart. 

Atresia  at  and  after  Puberty. — Whilst  before  puberty- 
true  atresia  gives  rise  to  no  symptoms  and  is  rarely  discovered 
even  by  accident,  when  the  menstrual  functions  are  established 
important  symptoms  appear,  which  obhge  the  patient  to  seek 
for  medical  relief.  There  is  amenorrhoea,  and  the  gradual 
formation  of  a  tumour.  The  menstrual  fluid  distends  the 
vagina  above  the  obstruction,  the  molimen  is  felt,  but  there 
is  no  "  show."  Grradually  the  entire  vagina  becomes  dilated, 
then  the  cervix.  The  cavity  of  the  body  of  the  uterus  is  slow 
to  fill.  The  Fallopian  tubes  also  tend  to  become  distended 
with  blood,  not,  it  appears,  by  the  same  mechanism  which 
distends  the  vagina  and  uterus,  but  through  htemorrhage  from 
the  tubal  mucous  membrane.  Thus  the  tubes  may  be  completely 
cut  off,  by  closure  of  their  uterine  extremities,  from  the  uterus, 
and  yet  be  full  of  blood.     The  tubes  may  rupture,  with  fatal 

*  The  Surgical  Diseases  of  CMldren,  188.^. 


460  OPERATIONS    ON    THE    VAGINA,    ETC. 

results.  On  the  other  hand,  spontaneous  rupture  of  the 
obstructing  septum  is  most  unusual.  The  accumulation  of 
retained  menstrual  fluid  not  only  mounts  the  genital  canal  in 
the  way  described,  but  also  causes  bulging  in  the  region  of  the 
vulva  and  perineum,  and  forms  a  large  timiour,  very  tense  and 
elastic. 

The  retained  menstrual  blood  varies  greatly  in  amount. 
From  eight  or  ten  to  fift}^  or  even  over  a  hundred  ounces  have 
been  removed.  It  is  prevented  fi'om  coagulating  by  the  vaginal 
mucus,  and  some  of  its  fluid  is  probably  reabsorbed,  since  Puech 
has  noted  that  the  collection  in  a  given  case  is  less  than  might 
be  expected  on  calculating  the  accumulation  of  the  blood  shed 
at  each  period  before  observation.  It  is  dark  brown  in  coloui-, 
treacly  or  tar-Kke  in  consistence,  and  almost  or  c|uite  odourless. 
When  air  is  admitted  into  the  vagina,  this  fluid  rapidly  begins 
to  decompose. 

Symptoms. — Strange  to  say,  the  serious  pathological  con- 
ditions just  described  are  slow  to  produce  subjective  symptoms. 
This,  I  believe,  is  partly  o^dng  to  the  fact  that  young  girls 
have  not  learnt  to  pay  great  attention  to  occasional  dull  pains 
in  the  pelvic  and  lumbar  regions,  so  that  when  present,  the 
patient  troubles  less  about  them  than  she  would  were  she  older 
and  imbued  v,dth  the  physiological  ideas  and  superstitions  of 
adult  women.  Duncan  lays  stress  on  the  absence  of  symptoms. 
In  a  lectiu-e  on  Reteniion  of  Menses,  he  says :  "  In  two  recent 
cases  of  great  accumulation,  we  may  well  say  that  there  were 
no  symptoms  and  no  constitutional  disturbance.  Certainly, 
even  at  last,  there  was  no  constitutional  disturbance  in  either  of 
them.  In  one,  S.  P.,  aged  twenty-one,  a  florid  girl,  beaming  in 
health  and  vigom-,  it  was  only  eight  months  before  coming  into 
hospital  that  she  knew  she  had  a  lump  in  the  lower  belly ;  it 
was  discovered  accidentally  by  her  doctor,  who  happened  to 
examine  her  in  bed  for  a  passing  illness ;  and  she  had  no 
symptoms  till  the  doctor  told  her  she  had  this  lump.  Then  she 
began  to  find  out  that  she  had  irregular  achings,  for  about  the 
half  of  each  month,  probably  suggested,  or  what  are  called 
imaginary  symptoms."     The  last  sentence  is  highly  instructive. 

Pain,  however,  is  rarely  altogether  absent,  and  may  be 
strictly  periodical.     Retention  of  lu-ine  is  frequent.      Some  of 


ATRESIA    VAGIXiE. 


461 


the  symptoms  of  early  pregnancy,  sickness,  tenderness  of  the 
breasts,  and  slight  development  of  the  areolae  may  be  observed, 
and  lead  to  grave  suspicions,  greatly  increased  by  the  other 


Fig.  165.— Atresia  Vagix^,  avith  the  Hymen  well  developed  and 
FATULOiT.s.      (MattJieios  Duncan.) 

principal  symptoms  of  atresia,  which  are  amenorrhoea  and  the 
presence  of  a  swelling.     This  leads  to  the  subject  of  diagnosis. 

Diagnosis. — In    a    case   of   atresia,  the   objective   sjmiptoms 
just  given  will  be  present.      When,  in  a  young  patient  who 


462  OPERATIONS    ON    THE    VAGINA,    ETC. 

lias  never  seen  any  menstrual  "show,"  the  vagina  is  found  to 
be  closed,  the  vulva  and  probably  the  obstructing  septum  dis- 
tended, and  a  tumour  discovered,  the  diagnosis  of  atresia  will 
be  all  but  certain.  The  bulging  of  the  vulva  varies  in  character. 
Sometimes,  the  orifice  of  the  urethra  is  abnormally  patulous. 
The  hymen  may  be  found  entire,  pushed  in  front  of  the 
distended  septum  (Fig.  165,  Duncan's  case),  or  it  may  itself 
form  the  septum.  When,  in  an  adult  patient,  there  is  an 
undistended  blind  pouch  within  the  vulvar  orifice,  without 
any  tumoiu',  and  no  history  can  be  obtained  of  any  menstrual 
mohmen,  the  chances  are  that  the  internal  organs  are  unde- 
veloped or  absent.  The  pelvis  must  be  explored  by  rectal 
bimanual  (see  page  71)  and  recto-vesical  examination,  where 
a  catheter  or  sound  in  the  bladder  will  be  a  valuable  guide 
(page  72).  The  surgeon  must  not  conclude  that  the  uterus 
and  ovaries  are  fairly  developed  because  the  patient  looks 
like  an  ordinary  woman.  Six  years  ago,  I  examined  a 
3'oung  married  woman,  about  twenty-three  years  of  age, 
whose  breasts  were  well  developed,  and  the  labia  and  clitoris 
well  formed,*  but  the  vagina  was  reduced  to  a  blind  pouch 
hardly  an  inch  deep  on  pressure.  This  pouch  was  employed 
functionally,  but  all  sexual  desire  was  absent.  She  had  never 
menstruated.  "  Imperforate  hymen  "  had  been  diagnosed,  but 
not  a  trace  of  uterus  or  of  the  vagina  above  the  pouch  could  be 
detected.  The  bladder  and  rectum  were  almost  in  contact;  any 
attempt  to  puncture  or  dissect  through  the  blind  pouch  would 
have  ended  in  failure,  if  not  in  disaster. 

In  simple  atresia,  without  deficiency  of  the  uterus,  there  will 
not  only  be  distension  in  the  vulvar  and  perineal  region,  but 
also  a  tumour,  which  may  reach  high  in  the  abdomen.  The 
closure  of  the  vagina  will  preclude  pregnancy.  The  tumour 
balges  towards  the  rectum,  where  it  can  be  felt  as  a  tense 
elastic  bag.  The  distension  of  one  or  both  Fallopian  tubes 
may  be  detected.  In  a  case  recently  under  the  care  of  Mr. 
Mayo  Robson,  where  the  vagina  was  considerably  deficient, 
the  right  tube  formed  "  a  prolongation  like  a  sausage." 

*  See  plate  III.  in  Duiicairs  "Case  of  so-called  Imperforate  Hymen"  already 
<[uoted  (page  9),  It  represents  the  well-formed  external  parts,  inehiding  the 
liymen,  of  a  woman  in  whom  the  vagina  and  uterus  were  ahsent. 


OPERATION    FOR    ATRESIA.  463 

The  amount  of  perineal  bulging  in  relation  to  the  size  of  the 
elastic  tumour  which  can  be  felt  through  the  rectal  walls  and 
above  the  pubes,  is  a  point  of  considerable  diagnostic  value. 
When  the  tumour  is  present,  and  the  bulging  of  the  perineum 
and  vulva  distinct,  the  obstruction  probably  lies  in  the  hymen, 
or  low  down  in  the  vagina.  When  the  tumour  is  present,  but 
no  bulging  can  be  detected  in  the  perineal  and  vulvar  regions, 
the  vagina  will  probably  be  deficieni  to  a  considerable  extent. 

Operation. — All  authorities  agree  that  operations  for  the 
relief  of  atresia  are  of  a  very  serious  character.  It  must  be  re- 
membered that  the  operation  has  to  be  done,  else  the  retention 
of  menses  will  continue,  and,  owing  to  its  toughness,  the 
obstructing  septum  is  not  likely  to  yield,  whilst  some  in- 
ternal part  of  the  swelling  may  burst.  However  simple  the 
malformation  may  look,  more  of  the  vagina  may  be  involved 
than  might  be  expected,  so  that,  instead  of  a  simple  puncture 
or  incision,  a  difficult  dissection  will  be  needed.  Lastly,  the 
opening  up  of  a  cavity  full  of  decomposable  material,  and 
walled  in  by  the  tissues  of  important  structures,  must  in- 
evitably expose  the  patient  to  risk.  Hence  the  surgeon  must 
make  up  his  mind  for  an  operation,  and  must  be  very  careful 
how  he  performs  it,  and  how  he  carries  out  the  after-treatment. 

An  excellent  method  of  operating  for  atresia  is  adopted  by 
Dr.  Matthews  Duncan  in  the  wards  for  diseases  of  women  at 
St.  Bartholomew's  Hospital.  I  know  that  the  results  are  satis- 
factory. It  is  best,  I  believe,  to  follow  the  advice  of  Hart  and 
Barbour  and  others,  and  to  operate  between  two  menstrual 
molimina,  as  far  as  can  be  calculated.  The  patient  is  placed 
in  the  lithotomy  position,  and  an  incision  an  inch  long  is  made 
in  the  region  of  the  hymen,  running  from  before  backwards. 
It  is  not  necessary  to  make  the  incision  crucial.  PaqueHn's 
cautery-knife  answers  this  purpose  far  better  than  a  scalpel. 
Layer  after  layer  is  divided,  until  the  thick  treacly  retained 
fluid  flows  freely,  accelerated  at  each  inspiration.  The  surgeon 
must  judge  in  each  particular  case  how  long  tlie  incision  should 
be ;  it  must  be  more  than  a  mere  hole  just  allowing  the  fluid  to 
flow,  and  must  not,  of  course,  be  prolonged  so  as  to  damage  the 
bladder,  urethra,  or  rectum.  The  septum  often  jDroves  to  be 
thick  and  tough. 


46-1  OPERATIOXS    OX    THE    VAGINA,    ETC. 

The  fluid  must  be  allowed  to  flow,  without  any  assistance  by 
pressing  on  the  abdominal  walls,  or  on  the  rectal  side  of  the 
recto-vaginal  septmn  ;  nor  is  it  necessary  or  advisable  to  use  the 
syringe  dming  operation.  When  the  fluid  has  ceased  to  flow 
freely,  lint  soaked  in  carbolic  oil  is  laid  over  the  vulva,  and 
the  patient  is  placed  in  bed,  with  napkins  carefully  adjusted  to 
receive  further  discharge. 

The  characteristic  discharge,  as  a  rule,  flows  for  a  few  days, 
and  the  next  coloured  discharge  is  generally  brighter,  repre- 
senting the  unobstructed  menstrual  "  show."  The  forefinger 
should  be  introduced  between  the  edges  of  the  wound  two  or 
three  times  a  week.  In  eight  or  ten  days  the  wound  is 
usually  healed.  Duncan  strongly  advises  that  the  patient 
should  remain  in  bed  for  three  or  four  weeks,  in  order  that  the 
restoration  of  the  vagina  and  uterus  to  a  natural  state  may 
meet  wdth  no  interruption.  When  the  patient  is  quite  young, 
and  the  amount  of  retained  fluid  does  not  exceed  from  ten  to 
twentv  ounces,  the  vagina  presents  but  little  abnormality.  As 
a  ride,  however,  its  walls  are  at  flrst  exceedingly  thick  and 
hard,  through  true  hypeiirophy,  and  Breisky  noted,  during 
digital  exploration  of  one  ease  a  week  after  operation,  that  they 
then  underwent  povverful  and  painful  contractions.  He  seems 
to  imply  that  these  spasms  were  caused  by  the  hypertrophied 
muscular  walls  of  the  vagina,  and  not  by  the  sphincter  vagince 
and  levator  ani,  which  so  often  contract  when  the  genitals 
receive  any  painful  impression  (page  48).  The  mucous  mem- 
brane forms  thick  transverse  folds.  The  cervix  uteri  is 
difficult,  at  first,  to  reach ;  indeed,  its  vaginal  portion  appears 
very  frequently  to  be  ill-developed.  The  vagina  slowly  gains 
its  normal  character. 

Dr.  Matthews  Duncan  claims  the  best  results  for  his  cases 
"treated  by  Paquelin's  cautery  incision  and  otherwise  left 
alone."*  Indeed,  syringing  sometimes  appears  to  set  up  septic 
or  other  dangerous  symptoms. 

No  doubt,  symptoms  of  blood-poisoning  may  follow  the  most 

*  In  December,  1886,  Dr.  Duncan  kindly  wrote  to  me  in  reply  to  a  letter  ou 
this  important  featiire  in  after-treatment — "  I  regularly  use  no  syringing  after 
hjematocolpos  operation.  If  there  is  much  of  yellow  discharge,  a  warm  wash  out 
by  syringe  may  be  ulteriorly  used.     Generally  that  is  not  required." 


OPERATION    FOR    ATRESIA DEFICIENCY    OF    VAGINA.         465 

carefully  performed  operation  of  this  kind.  This  is  probably 
due  to  the  decomposition  of  some  of  the  fluid  which  lies  in 
a  part  of  the  affected  tract,  whence  it  cannot  be  readily  dis- 
lodged by  muscular  contractions.  The  flow  of  the  treacly  fluid 
backwards  through  the  tubes  into  the  peritoneal  cavity  has  been 
known  to  occur  ;  it  has  been  explained  differently  by  various 
authorities.  Some  speak  of  reversed  peristaltic  action  of  the 
tubes,  excited  by  the  escape  of  fluid.  The  action  being  directed 
backwards,  some  fluid  is  forced  into  the  peritoneal  cavity. 
Others  think  that  the  tubes  rupture  by  sudden  contractions 
too  violent  to  expel  their  contents  steadily.  Others  believe  that 
the  tubes  are  often  fixed  by  old  adhesions  to  the  pelvic  walls. 
When  the  fluid  escapes,  the  distended  uterus  collapses  and 
sinks  downwards,  dragging  on  the  tubes  until  one  of  them  is 
ruptured  and  allows  the  escape  of  its  contents  into  the  peri- 
toneal cavity.  This  last  remarkable  condition  has  been  proved 
by  dissection.  These  evil  results  all  warn  the  surgeon  to  be 
very  careful  about  after-treatment,  and  to  allow  the  fluid  to 
empty  itself  slowly,  so  that  the  contractions  of  the  distended 
parts  may  be  slow,  uniform,  and  steady,  ensuring  the  expul- 
sion of  all  the  fluid,  and  avoiding  sudden  traction  on  any 
delicate  structure. 

Deficiency  of  the  Vagina. — By  this  term  I  imply  absence 
of  more  or  less  of  the  vagina,  with  or  without  retention  of 
menses. 

Deficiency  of  the  lower  part  of  the  vagina,  a  tract  of  tissue 
rather  than  a  mere  septum  lying  between  it  and  the  ATilva,  with 
retention  of  menses,  is  an  affection  bearing  most  of  the  char- 
acters of  atresia  as  already  defined  and  described,  nor  can  the 
two  conditions  be  readily  distinguished.  The  sac  of  retained 
menses  may  bulge  towards  the  vulva,  as  in  simple  atresia. 
Unfortunately,  in  some  cases  of  retention,  not  even  a  tract  of 
tissue  lies  between  the  vulva  and  the  upper  part  of  the  vagina, 
but  the  walls  of  the  bladder  and  rectum  lie  close  together. 

This  last  condition  is  yet  more  frequent  when  no  menses  are 
retained,  and  when  no  molimen  has  been  experienced  by  the 
patient.  As  I  have  already  stated  (page  462),  the  internal 
organs  may  be  ill-developed  when  all  the  external  physical 
attributes  of  a  perfect  woman  are  present. 

H    H 


466  OPERATIONS    OX    THE    VAGINA,    ETC. 

Treatment. — When  a  sac  of  retained  menses  can  be  plainly 
detected,  the  patient  may  be  subjected  to  the  operation  for 
atresia,  great  care  being  taken  to  ascertain,  by  means  of  the 
catheter  in  the  bladder  and  the  finger  in  the  rectum,  how  near 
those  viscera  may  lie  to  one  another.  When  it  is  evident  that 
the  bladder  and  rectum  are  in  very  close  contact,  either  a 
vaginal  passage  must  be  dissected  out  between  them,  as  will 
be  described,  or  else  the  collection  of  menses  must  be  emptied 
by  puncture  through  the  rectum. 

Where  no  collection  of  retained  menses  can  be  found,  the 
presence  and  relations  of  the  uterus  must  be  carefully  ascertained 
by  recto-abdominal  and  vesico-rectal  exploration  (page  71). 
That  organ  may  prove  to  be  altogether  absent  or  quite  impal- 
pable, owing  to  extreme  atrophy  or  rather  arrested  development. 
On  the  other  hand,  a  little  tough,  anteflexed  virgin  uterus  may 
be  distinctly  defined  ;  the  cervix  may  even  be  detected  by  simple 
rectal  exploration. 

Opinions  are  much  divided  as  to  the  advisability  of  an  opera- 
tion in  these  cases.  In  the  first  place,  when  no  uterus  is 
discovered  after  careful  exploration,  I  believe  that,  for  many 
reasons,  no  operation  should  be  performed. 

The  case  is  othermse  when  a  uterus  can  be  distinctly  felt. 
The  ethical  aspects  of  an  operation  for  the  formation  of  a 
functional  vagina  must  be  considered.  The  uterus,  though 
formed,  is  probably  a  sterile  uterus,  so  that  the  vagina  wiD.  only 
serve  one  function  and  never  give  transit  to  a  foetus  or  even  to 
catamenial  blood.  Yet  the  unexpected  establishment  of  men- 
struation after  an  operation  of  this  kind  is  not  unknown. 

Dr.  Matthews  Duncan  entirely  discountenances  the  artificial 
dissection  of  a  vagina.  He  declares  that  judging  from  past 
experience  "  the  attempts  to  make  a  new  vagina  result  in  a 
troublesome  and  most  imperfect  imitation  of  nature,  as  bad, 
indeed,  as  the  new  noses  that  sm'geons  amuse  themselves  by 
making."  The  wound  becomes  a  cicatricial,  indurated  passage, 
constantly  needing  dilatation.  There  can  be  no  doubt  that 
the  good, results  claimed  by  certain  operators  are  too  often  tem- 
porary. 

Nevertheless,  when  the  fundus  and  cervix  can  be  distinctly 
felt,  circumstances  may  render  an  operation  advisable. 


DEFICIENCY    OF    THE    A'AGINA CICATRICIAL    ATRESIA.         467 

Operation  for  Deficiency  of  the  Vagina. — The  patient 
must  be  placed  in  the  lithotomy  position,  an  assistant  holds  a 
sound  in  the  bladder  as  in  lithotomy,  and  at  the  same  time 
presses  with  his  disengaged  hand  on  the  abdominal  walls  imm.e- 
diately  above  the  pubes,  so  as  to  push  the  uterus  well  downwards. 
A  bougie  or  the  forefinger  of  an  assistant  is  kept  in  the  rectum ; 
the  operator  will  not  find  it  convenient  to  keep  his  own  left 
hand  engaged  for  that  purpose. 

There  is  rarely  room  between  the  urethra  and  anus  to  allow 
of  a  fairly  long  antero-posterior  incision ;  it  is,  therefore,  gene- 
rally necessary  to  make  it  transverse.  With  the  usual  appli- 
ances for  checking  haemorrhage,  the  connective  tissue  above  the 
incision  must  be  carefully  broken  down  with  the  forefinger. 
The  operator  will,  in  that  waj^  generally  manage  to  push 
between  the  bladder  and  rectum  until  he  opens  up  the  upper  or 
patent  part  of  the  vagina  or  reaches  the  cervix.  He  must  bear 
in  mind  possibility  of  congenital  malformations  such  as  double 
vagina  or  uterus.  The  open  tract  is  packed  for  about  twenty- 
four  hours  with  lint  soaked  in  carbolized  oil.  Then  a  special 
vaginal  plug  must  be  kept  in.  Several  forms  are  sold  by  instru- 
ment makers ;  the  best  is  made  of  glass,  and  constructed  so  that 
it  may  be  fixed  with  tapes  to  a  bandage  passed  round  the  abdo- 
men. It  should  be  perforated,  and  removed,  cleaned,  and 
replaced  daily.  After  a  few  weeks  the  patient  must  learn  to 
introduce  and  remove  the  plug  daily.  This  must  be  done  for 
at  least  a  year,  and  is  often  advisable  throughout  the  whole  of 
the  patient's  life  until  the  end  of  the  child-bearing  term,  as  far 
as  that  can  be  estimated  in  a  subject  neither  likely  to  menstruate 
nor  to  bear  children,     A  Hodge's  pessary  is  useful  as  a  dilator. 

Acquired  Atresia  and  Contraction  of.  the  Vagina. 
— The  vagina  is  sometimes  greatly  obstructed  by  cicatricial 
changes  following  injuries  received  during  labour,  wounds, 
and  syphilitic  ulceration.  Adhesion  of  sm'faces  of  its  mucous 
membrane  in  apposition,  as  a  result  of  inflammation,  has  been 
observed  even  after  parturition. 

The  worst  and  most  frequent  cases  of  acquired  atresia  are  the 
result  of  damage  during  labom' ;  contrary  to  the  rule  in  the  con- 
genital forms,  it  is  the  upper  part  of  the  vagina  Avhich  is 
generally  involved.     Small  cicatrices  are  often  observed  in  the 


468  OPERATIONS    ON    THE    VAGINA,    ETC. 

course  of  digital  exploration  in  the  out-patient  room.  They 
form  elevated  spiral  or  crescentic  ridges  running  from  the 
cervix  downwards  along  the  walls  of  the  vagina.  Their  edges 
are  generally  sharp,  and  they  feel  tough  like  cicatrices  elsewhere. 
The  cervix  is  often  displaced,  and  the  cicatrices  may  he  so  much 
developed  that  the  finger  can  only  with  difficulty,  if  at  all,  be 
brought  in  contact  with  the  os,  Matthews  Duncan  writes 
{Clinical  Lectures)  :  "  But  though  cases  of  stricture  more  or  less 
tight,  and,  having  a  small  lumen  from  these  causes,  are  not 
uncommon,  I  have  not  seen  one  of  complete  closure  (atresia) 
with  retention  and  accumulation." 

Operative  Treatment. — Small  crescentic  cicatrices  should 
not  be  interfered  with.  When  the  cicatrization  is  extensive, 
threatening  difficulties  in  futiu-e  labours,  and  causing  marked 
displacement  or  dyspareunia,  some  of  the  more  prominent 
bands  should  be  notched  by  means  of  a  probe-pointed  bistoury, 
A  vaginal  dilator  (page  424)  must  afterwards  be  inserted  ;  the 
patient  will  require  frequent  attention  for  many  years  after  this 
proceeding.  When  there  is  real  atresia,  with  retention  of 
menses,  the  most  bulging  part  of  the  vaginal  swelling  should 
be  cautiously  opened  by  means  of  the  thermo-cautery,  and  the 
<3ase  is  afterwards  treated  as  when  a  congenital  septum  is 
opened ;  but  when  the  accumulated  menstrual  fluid  has  come 
away,  a  vaginal  dilator  must  be  worn.  The  surgeon  must  not 
only  remember  the  dangers  attending  operative  measures  in 
these  cases  of  acquired  contraction  and  atresia,  but  must  be 
prepared  for  discouraging  results. 

Atresia  of  the  Cervix  Uteri. — The  treatment  of  this 
affection  by  operative  measures  has  been  already  described  at 
page  338. 

Removal  of  Tumours  of  the  Labia. — When  a  labium 
is  affected  with  hypertrophy,  or  with  a  tumour  innocent  or 
malignant,  it  is  best  to  remove  it  by  means  of  the  galvano- 
•cautery.  The  galvanic  ecraseur  is  not  so  easy  to  guide  as  a 
wire  attached  to  the  two  cHp-handles  already  described  and 
figured  (page  153).  The  patient  is  placed  in  the  lithotomy 
position,  the  affected  labium  is  seized  by  means  of  a  strong 
volsella,  held  by  an  assistant.  The  operator  takes  a  handle  in 
each  hand  and  guides  the  wire,  heated  to  a  red  heat,  through 


AMPUTATION    OF    CLITORIS — URETHRAL    CARUNCLE.         469 

the  integuments  and  deeper  structures,  along  the  desired  line 
of  amputation,  till  the  labium  is  severed. 

When  the  knife  or  any  other  cutting  instrument  is  used, 
htemorrhage  will  be  severe,  and  a  Paquelin's  cautery  should  be 
at  hand.  The  platinum-knife,  worked  by  the  thermo-cautery, 
is  not  suited  for  dividing  the  integument,  it  does  not  cut 
cleanly  like  the  wire  of  the  galvano-cautery,  and  the  tissues 
consequently  heal  badly. 

Removal  of  Diseased  Clitoris. — True  hypertrophy  of 
the  clitoris  must  be  distinguished  from  the  apparent  hyper- 
trophy observed  when  the  other  external  organs  are  small  and 
ill  developed.  In  the  true  form,  alone,  is  an  operation  justifi- 
able. Epithelioma  may  commence  in  the  clitoris,  which  should 
then  be  amputated.  Removal  of  the  clitoris  must  never  be 
attempted  on  the  ground  that  it  may  cure  a  neurosis. 

The  galvano-cautery,  employed  as  in  the  case  of  diseased 
labia,  is  the  best  instrument  for  amputation  of  the  clitoris.  I 
have  been  present  when  the  knife  and  Paquelin's  cautery  were 
used  for  the  removal  of  an  epitheliomatous  clitoris.  The 
haemorrhage  was  difficult  to  check,  and  a  painful  cicatrix 
remained.  In  epithelioma,  the  adjacent  parts  of  the  labia  are 
often  involved,  and  will  require  removal.  Simple  dressing  with 
lint  steeped  in  carbolized  oil,  and  the  administration  of  opiates 
for  the  first  twenty-four  hours,  will  be  necessary.  As  a  rule 
the  parts  heal  quickly. 

Treatment  of  Urethral  Caruncle. — A  small  urethral 
caruncle  may  produce  no  symptoms,  and  may  be  discovered 
quite  accidentally,  in  searching  for  some  other  condition.  In 
such  a  case  it  is  not  justifiable  to  interfere  with  it.  On  the 
other  hand,  a  patient  may  complain  of  severe  local  pain,  difficidt 
micturition  and  other  symptoms,  attributed  to  a  prolapse  of  the 
uterus  or  vaginal  walls  which  really  exists.  Should  the  surgeon, 
on  examining  the  parts,  discover  a  urethral  caruncle  as  well, 
the  latter  affection  is  probably  the  chief  cause  of  the  painful 
symptoms. 

The  surgeon  must  refrain  from  two  lines  of  treatment 
frequently  adopted.  He  must  not  content  himself  with  pidling 
down  as  much  of  the  caruncle  as  the  forceps  or  tenaculum  will 
hold  without  crushing,  and  snipping  it  off.     In  that  case  the 


470  OPERATIONS    OX    THE    VAGINA,    ETC. 

operation  will  most  certainly  be  incomplete,  some  of  the  growth 
will  he  left  behind,  and  the  patient,  after  suffering  from  the 
smarting  of  the  wound,  will  soon  be  subject  once  more  to  the 
pain  of  the  original  disease.  Nor  must  he,  on  the  other  hand, 
smear  the  growth  or  the  entire  urethra  with  caustics :  a.  stick  of 
nitrate  of  silver  applied  to  the  urethi-a  will  cause  intense  pain 
at  the  time  of  its  introduction,  followed  by  temporary  relief, 
which  may  last  for  a  month  or  longer,  but  it  cannot  cure,  and 
is  more  disagreeable  to  the  patient  than  the  proper  mode  of 
treatment.  Operations  on  caruncles  are  looked  upon  as 
*'  minor  "  surgery,  and  consequently  enter  too  often  into  the 
category  of  bad  sul'ger3^  Cucaine  may  cover  malpraxis.  A 
painless  excision  does  not,  as  a  rule,  mean  a  complete  excision. 

Removal  of  Urethral  Caruncle. — The  right  treatment 
for  urethral  caruncle  is  excision  and  application  not  of  caustics, 
but  of  the  cautery  to  the  wound.  This  requires  that  the 
patient  should  be  placed  under  the  influence  of  an  anaesthetic. 
For  that  reason  some  sui*geons  prefer  cucaine  to  chloroform  or 
ether,  local  to  general  anaesthesia.  But  cucaine  does  not  alwaj's 
act  well,  and  the  parts  cannot  be  so  thoroughly  explored  when 
the  patient  is  conscious,  as  there  is  always  hypercesthesia. 

The  patient,  after  her  urine  has  been  drawn  off,  is  placed 
on  her  back,  and  the  anaesthetic  is  administered.  Then  her 
legs  may  be  kept  apart  by  a  Clover's  crutch  or  else  by  an 
assistant,  a  Sims'  speculum  is  passed  into  the  vagina  and 
depressed ;  the  labia  are  also  held  apart  anteriorly.  In  this 
manner  the  vestibule  and  meatus  are  brought  well  into  \'iew. 
In  the  meantime,  an  assistant  prepares  the  cautery.  The  finest 
point  of  a  Paquelin's  thermo-cautery  should  always  be  pre- 
feiTcd,  if  that  instrument  be  at  hand.  Should  no  special 
form  of  cautery  be  at  the  surgeon's  disposal,  any  fine-pointed 
piece  of  ii^on,  properly  mounted,  will  serve.  It  must  be 
made  as  hot  as  possible  in  the  fire  or  in  the  flame  of  a  gas- 
jet  or  candle.  A  fine-pointed  bradawl  has  been  frequently 
used  in  this  wa}^,  and  appears  to  answer  very  well. 

The  surgeon  first  dries  the  urethra  by  means  of  wool  wrapped 
round  the  point  of  a  Playfair's  probe.  He  then  seizes  the 
caruncle  with  a  fine  volsella,  or,  better  still,  transfixes  it  \\dth 
the  point  of  a  tenaculum.     Taking  the  forceps  or  tenaculum  in 


REMOVAL    OF    A    URETHRAL    CARUNCLE. 


471 


the  left  hand,  he  raises  the  caruncle  very  gently,  and  cuts 
through  its  base  with  scissors  curved  on  the  flat.  The  wound 
is  certain  to  bleed,  and  it  is  best  to  check  the  bleeding  by 
pressure  of  a  piece  of  wool,  mounted  as  above  described,  for 
half  a  minute  or  so.  Then,  when  the  bleeding  no  longer 
interferes  with  a  view  of  the  cut  surface,  the  cautery  is 
applied  to  that  surface,  just  long  enough  to  burn  its  tissues 
perceptibly. 

The  after-treatment  is  very  simple — the  patient  should  keep 
at  rest  for  a  couple  of  days,  and  the  ui'ine  should  be  drawn 
off,  if  possible,  twice  or  oftener  during  the  first  twelve  hours 
after  operation.  I  have  found  it  advisable  to  give  carbonate  of 
potash  with  tincture  of  hyoscyamus,  as  in  gonorrhoea,  during 
this  period.  Micturition  then  becomes  far  less  painful,  and 
when  the  patient  is  free  from  apprehension  of  pain,  there  is 


Fig.  166. — Cauters  for  Treatment  of  Urethral  Caruncle.* 


less  chance  of  trouble  in  this  respect  every  time  that  the  bladder 
is  emptied.  Indeed,  the  catheter  is  often  unnecessary  from 
the  fi.rst. 

Removal  of  Caruncle  by  the  Galvano-eautery. — 

For  the  removal  of  urethral  caruncles  by  the  galvano-eautery, 
an  anaesthetic  having  been  administered,  the  patient  is  placed 
in  the  lithotomy  position,  and  the  urine  drawn  off  by  a 
catheter.  The  knees  are  held  apart  by  assistants  or  a  Clover's 
crutch.  The  labia  are  protected  by  several  folds  of  wet  lint 
and  held  apart  by  the  fingers  of  assistants.  The  caruncle  is 
then  seized  by  a  small  volsella  or  by  a  pair  of  ordinary  artery- 
forceps,  and  a  short  loop  of  platinum  wire,  attached  to  handles 

*  The  second  cauter  in  this  drawing  is  useful  for  cauterizing  a  pin-hole  vesico- 
vaginal fistula,  left  after  operation  (see  p.  435). 


472  oPERAT^o^'s  ox  the  vagina,  etc. 

as  in  Fig.  72,  or  to  an  ecraseur  (Fig.  70)  is  passed  down  to 
the  base  of  the  carnncle.  "When  the  loop  is  adjusted  the 
circuit  is  closed  and  the  gro'U'th  is  veiy  Cjuicklj  removed,  the 
■^ire  being  raised  to  a  red  heat.  No  bleeding  ought  to  take 
place,  but  it  is  best  to  cauterize  the  base  of  the  growth  by  the 
hot  vnie  or  by  a  platinum  point  (Fig.  166).  Some  surgeons 
prefer  to  use  the  platinum  knife  (Fig.  69) ;  but  the  loop  of 
platinum  wire  is  better  for  this  operation.  After  the  removal 
of  the  caruncle  a  piece  of  lint  dipped  in  carbolic  oil  is  placed 
between  the  parts,  and  held  in  position  hy  a  T-bandage.  The 
after-treatment  will  be  as  above  described. 

Urethro -Vaginal  Fistula. — The  operation  for  this  aifec- 
tion  is  described  in  Chapter  XYL,  page  437. 


For  the  principles  on  which  Dilatation  of  the  Urethra 

should  be  conducted  for  pm-poses  of  diagnosis  or  for  facilitation 
of  operative  measui"es,  the  systematic  text-books  on  diseases  of 


Fig.  167. — Simox's  Dilator,  with  the  Plug  Ixserted. 

women  must  be  consulted.  The  general  surgeon  must  be  very 
slow  to  imdertake  dilatation  of  the  lu-ethra,  as  it  may  be 
followed  by  intractable  incontinence  of  mine,  even  when 
performed  by  an  experienced  hand. 

For  the  extraction  of  small  calculi,  dilatation  by  Simon's 
instrument  (Fig.  167),  may  prove  very  satisfactory.  I  have 
removed  a  stone  measuring  an  inch  in  its  long  diameter,  and 
weighing  two  di-aehms  and  a  half,  from  the  bladder  of  a  child 
aged  nine,*  after  dilatation  mth  that  instrument,  and  the 
patient  regained  power  over  the  bladder  in  a  few  hoiu's  ;  I  last 
saw  her  four  years  after  the  operation,  and  then  she  was  in 
perfect  health.  I  have  learnt  from  others,  however,  that 
incontinence  of  urine  has  followed  a  very  trifling  amount  of 
dilatation. 

*  Medical  Press  and  Circular,  1878,  p.  66. 


SUPKA-PUBIC    OPERATION.  473 

Operations  on  the  Female  Bladder  do  not  lie  precisely 
within  the  scope  of  this  handbook.  It  is  probable  that  the  Supra- 
pubic Operation  will  supersede  all  other  forms  of  lithotomy 
and  all  operations  for  calculus,  when  the  stone  is  large.  Some 
surgeons  advocate  lithotrity  for  large  calculi  in  women.  For 
small  calculi  the  operation  above  described  is  still  preferred. 
Vaginal  lithotomy  is  not  likely  to  be  widely  practised.  The  supra- 
pubic operation  may  be  undertaken  for  the  removal  of  tumours  of 
the  bladder.  Sir  Henry  Thompson,  Mr.  Pye,  Mr.  R.  W.  Parker, 
and  others  have  successfully  removed  morbid  growths  by  this 
operation.  The  last-named  surgeon  employed  the  aid  of  the 
electric  lamp  (Fig.  73),  and  a  galvanic  ecraseur  of  a  slender 
make  was  passed  into  the  bladder  through  the  urethra.  The  loop 
of  platinum  wire  was  then  slipped  round  the  growth,  which  was 
removed  without  loss  of  blood.  Nevertheless,  this  operation  is 
still  in  the  hands  of  hardy  pioneers  or  surgeons  of  ver}-  wide 
experience ;  it  is  not  yet  so  far  established  as  to  be  a  suitable 
subject  for  this  manual.  The  reader  will  find  a  valuable  series  of 
papers  on  the  supra-pubic  operation  in  the  second  volume  of  the 
British  Medical  Journal  for  the  year  1886.  The  report  of  the 
"  discussion  on  Supra-pubic  Lithotomy,"  opened  by  Sir  Henry 
Thompson  in  the  section  of  Surgery  at  the  fiity -fourth  annual 
meeting  of  the  British  Medical  Association,  is  partieularl}' 
instructive. 


474 


ADDE^^DIJM   0^   DRAINAGE. 

Management  of  the  Drainage-Tube. — The  manner  of 
introducing  the  drainage-tube  is  described  at  page  126.  After 
ovariotomy,  oophorectomy,  or  any  other  form  of  abdominal 
section  where  a  glass  drainage-tube  is  introduced,  the  tube 
should  be  emptied  every  two  houi-s.  The  lower  strips  of  the 
binder  are  undone  (page  131),  the  india-rubber  cloth  (page  128) 
is  unfolded,  and  the  conical  sponge,  which  is  placed  over  the 
orifice  of  the  tube,  is  removed  and  dropped  into  a  1-in-lO 
solution  of  sulphurous  acid.  The  india-rubber  tubing  attached 
to  the  syringe  (page  127)  must  be  dipped  into  the  same  solu- 
tion before  it  is  passed  into  the  drainage-tube,  which  being 
done  as  described  at  page  128,  the  fluid  is  placed  in  a  glass 
vessel  for  examination,  and  more  is  then  removed  if  necessary. 
It  is  advisable  to  dip  the  tubing  into  a  l-in-20  solution  of 
sulphurous  acid  every  time  before  its  re-introduction  into  the 
drainage-tube.  When  all  the  fluid  is  removed,  a  fresh  conical 
sponge,  well  washed  out  in  a  l-in-5  solution  of  the  acid,  is 
jDlaced  over  the  orifice  of  the  drainage  tube  and  enveloped  in 
the  india-rubber  cloth.  The  sponge  not  in  use  should  be  kept 
in  a  1-in-lO  solution  of  the  acid. 

When  the  fluid  which  rises  in  the  tube  has  become  quite 
pale  and  only  amounts  to  a  drachm,  or  less,  at  each  dressing 
the  tube  may  be  removed.  The  orifice  in  the  wound  through 
which  it  passed  should  be  dressed  with  a  pad  of  absorbent  gauze. 
The  tube  must  never  be  taken  out  as  long  as  the  fluid  remains 
of  a  reddish  colour  or  smells  sour. 


INDEX. 


Ab'loininal  binder,  many-tailed,  etc., 
129.     Application  of,  130,  242. 

Abdominal  gestation,  352. 

Abdominal  section.  See  Ovariotomy, 
Oophorectomy,  etc. 

Abdominal  tumours,  diagnosis  of,  165, 
172.  Examination  of,  168.  Table 
of,  for  diagnosis,  174. 

Abdominal  wound  in  ovariotomy,  185, 
200.  Abscess  in  suture-track  in, 
241.  Cicatrix  of,  253.  Closure 
of,  239.  Dressing  of,  240.  Her- 
nial distension  of,  254.  Length 
of,  185  Mechanism  of  distension 
of,  after  operation,  251,  255. 
Rapidity  of  its  healing,  241. 
Sutures  for,  119,  185.  Union  of 
edges  delayed,  185. 

Abdomino-recto-vaginal  examination, 
72. 

Abscess  after  ovariotomy,  241,  266. 

Absorbent  wool  and  gauze,  how  to 
test,  131. 

Accessory  fimbria  on  Fallopian  tube, 
25. 

Adams'  peritoneum -hook,  101,  203. 

Adhesions  :  In  ovariotomy,  abdominal, 
212.  Pelvic,  216.  In  hysterec- 
tomy, 289. 

Administrator  of  anesthetics.  See 
Chloroformist. 

Ague  and  high  temperature  after  ovari- 
otomy, 258. 

Alexander,  Dr. ,  his  operation  for  shor- 
tening the  round  ligaments,  413. 

Ampere,   144. 

Anesthesia,  etc.     See  Chloroformist. 

Apartment  for  ovariotomy  patient,  187. 

Aperients.     See  Purgatives. 


Appendages,  uterine,  inflammation  of, 
275.     See  Oo'jiihorectoray . 

Apron,  mackintosh,  for  operator,  197. 

Arteries  of  the  pelvis,  37. 

Artery  :  Azygos,  of  vagina,  38.  Of  cer- 
vix uteri,  41.  Coronary  of  cervix, 
41.     Iliac,  common  and  external, 

37.  Internal,  38.  Iliac  in  rela- 
tion to  ureters,  31.     Ovarian,  37, 

38.  Ovarian,  how  di\aded  in 
ovariotomy,  39.  Uterine,  39. 
In  hysterectomy,  297.  In  supra- 
vaginal excision  of  cennx,  331. 
In  vaginal  extirpation  of  uterus, 
321. 

Aspiration  of  ovarian  cysts,  177,  179. 

Assistants  during  ovariotomy,  number 
of,  199. 

Atresia  :  Of  the  cervix,  Breisky's  opera- 
tion for,  338.  Of  the  vagina, 
9,458.  Operation  for,  463,  Cica- 
tricial, 424,  445,  467. 


B 


Bandage,  abdominal.  See  Ahdoniinal 
Binder. 

Bantock,  Dr.  G.  Gran^-ille,  case  of 
colpocleisis,  445.  Koeberle's  serre- 
nteud,  his  moditicatiou  of,  123. 
Ligature  of  ovarian  pedicle,  his 
method  of,  ?20.  Pregnant  fibroid 
uterus,  his  case  of  removal  of.  385. 
On  opium  after  perineorrhaphy, 
398.  Application  of  large  pressure- 
forceps  to  pedicle,  219,  280. 
Ruptured  perineum,  his  operation 
for.  392.  Sutures  in  abdominal 
wound,  his  arrangement  of,  during 
the  cleaning  of  peritoneum,   236. 

Barnes'  speculum,  65. 


476 


INDEX. 


Basins,  objectionable  as  receptacles  for 
instruments  during  abilomiual 
section,  84. 

Bath  to  receive  ovarian  fluid,  etc.,  85. 

Battery,  bichromate  of  potash,  144, 
Bunsen's  147,  Grove's  148. 

Bed  for  ovariotomy  ])atient,  189. 

Bed-room  for  ovariotomy  patients,  187. 

Bed-pan,  difficulty  of  micturition  into, 
a  cause  of  cystitis,  257. 

Bed-sores  after  ovariotomy,  247.  After 
operations  in  extra-uterine  preg- 
nancy, 365,  368. 

Belt,  abdominal,  255.  See  also 
Abdominal  Binder. 

Belt,  thigh,  for  ovariotomy,  86. 

Bichromate  of  potash  battery.  144. 

Bimanual  examination,  53.  Recto- 
abdominal  bimanual,  71.  Ab- 
domino-recto-vaginal  bimanual, 
72. 

Binder.  See  Abdominal  Binder,  many- 
tailed. 

Bivalve  speculum,  66. 

Bladder,  27.  Extroversion  of,  449. 
Inflannnation  of,  after  ovariotomy, 
256.  After  operation  for  vesico- 
vaginal fistula,  435.  See  Vesico- 
vaginal fistula,  etc.  Supra-pubic 
operation,  observations  on,  473. 
For  application  of  ice,  137. 

Boultun,  Dr.  Percy,  his  self-retaining 
catheter,  433.  His  needle  for 
vesico-vaginal  fistula,  429.  Purse- 
string  operation  for  ruptured  peri- 
neum, as  performed  by,  399.  His 
speculum  for  trachelorrhaphy,  341. 
Case  of  urethro- vaginal  fistula,  437. 

Bowels,  opening  the,  after  ovariotomy, 
247. 

Bozeman.  Speculum,  62.  His  operation 
for  vesico-vaginal  fistula,  426. 

Breisky,  his  operation  for  atresia  of  the 
cervix,  338.  On  Miiller's  ducts,  8. 
On  vaginal  walls  in  atresia,  464. 

Broad  ligament,  35.  Relation  to  Fal- 
lopian tube,  23. 

Broad  ligament  cysts,  simple  or  "par- 
ovarian" cysts,  163.   Tapping,  180. 

Bronchitis,  cau.se  of  rise  of  temperature 
after  ovariotomy,  258. 

Bryant,  Mr.  Ovariotomy-trocar,  103 
H'jte. 

Bulb  of  ovary,  26,  4:i.     Of  vagina,  44. 

Bunsen's  Ijattery,  147. 

Burrowing  of  ovarian  cysts  beneath 
peritoneum,  226. 

Byrne,  Dr.,  ou  the  galvano-cautery  in 
elongated  cervix,  335. 


Cesarean      section,      369.       Sanger's 

modified,     370.       His    rules    for 

simplification  of,  375. 
Calculus    formed    around    ligature    of 

ovariotomy  pedicle    escaped    into 

bladder,  266. 
Cancerous    uterus,     removal    of.     See 

Vaginal  extirpation  of  uterus. 
Caneva,  his  hysterorrhaphy,  413. 
Cannula,  103  and  note.     Fitch's  dome- 
shaped,  105. 
Capsuled  or  encapsuled  ovarian  cysts, 

225.     Management  of,  227. 
Carunculie  myrtiformes,  9. 
Caruncle,  urethral,  469. 
Case-book  for  ovarian  cases,  167,  192. 
Catheter,  Boulton's,'Yor  vesico-vaginal 

and   urethro -vaginal  fistula,    433. 

After  ovariotomy,  191,  250. 
Cauters  for  galvano-cautery,  149.     For 

urethral  caruncles,  470. 
Cautery  in  ovariotomy,  185. 
Cervix  uteri,  20.     In  digital  explora- 
tion,    50.       Not    tender     to 
touch,  50,  52.     Artery  of,  41. 
Coronary  arterj'  of,  41. 

—  Amputation     of,     for     cancer, 

with  use  of  caustics,  332. 
By  ecraseur,  328.  By  gal- 
vano-cautery, 325.  By  knife 
and  scissors,  333. 

—  Atresia  of,    Breiskv's  operation 

for,  338. 

—  Electrolysis  in  cancer  ot,  338. 

—  Elongation   or   primary  hyper- 

trophy of,    334.      Operations 
for  relief  of,  335. 
— •     Laceration  of,   339,     Operation 
for.     See  Trachclorr/iaphy. 

—  Supra-vaginal  excision  of,  330. 
Champneys,  Dr.     On   extroversion    of 

the  bladder,  449. 
Chloroformist     in     ovariotomy,     197, 

198. 
Cicatricial  atresia  of  vagina,  424,  445, 

467. 
Cicatrix    of    abdominal    wouml    after 

ovariotomy.  See  Abdominal  wound 

in  ovariotomy. 
Cintrat's  serre-nceud,  124. 
Clamp,  in  ovariotomy,  185. 
Clamp,  Koeberle's.     See  Serrc-noiiul. 
Clii)-liandles,  for  galvanic  ecraseur,  153. 
Clitoris,      4.      Amputation     of,     469. 

Bifid  in  epis])atlias,  449. 
Clover's  crutch,  132. 


INDEX. 


477 


Cocaine     in     treatment     of    urethral 

caruncle,  470. 
Coe,    Dr.     On    unsatisfactory    results 

after  oophorectomy,  276. 
Colpocleisis,  442. 

Colporrhaph}'.     See  Elytror7'haphy. 
Conservative   surgery   of    the    uterine 

appendages,  277. 
Corkscrew,  Tait's,  287,  290. 
Coryza    and    high    temperature   after 

ovariotomy,  258. 
Coulomb,  144. 

CoAvper's  ducts,  12.     Gland,  12. 
Crescent  speculum,  Barnes',  65. 
Crutch,  Clover's,  132. 
Cucaine     in    treatment     of    urethral 

caruncle,  470. 
Cul-de-sac,     posterior      vaginal.      See 

Fornix,  j^osterior  vaginal. 
Cusco's  speculum,  67. 
Cystic  diseases  of  uterine  appendages, 

surgical  pathology  of,  158. 
Cyst-forceps.      See     Large     pressure- 
forceps,  Nelaton's,  107. 
Cystitis  :  After  ovariotomy,  256.  After 

repair    of    vesico-vaginal    fistula, 

435. 


D 


Dermoid  ovarian  tumour,  161. 

Deroubaix  on  vesico-vaginal  fistula,  419. 

Dieffenbach's  elytrorrhaphy,  407. 

Diet  after  ovariotomy,  243.  Milk-,  and 
formation  of  scybala,  244,  398 . 

Digital  exploration  of  vagina,  46. 

Dilator,  Simon's  urethral,  472.  Vag- 
inal, 425. 

Director:  Key's,  102.  Stanley's,  102, 
204. 

Discoloration  of  vulva  in  pregnancy, 
3,  46. 

Dohrn:  On  absence  of  vaginal  secretion 
in  atresia,  459.    On  the  hymen,  4. 

Dome-trocar,  Fitch's,  103  note,  105. 

Douglas's  pouch,  19,  34. 

Drainage,  126,  474.  Primary,  126. 
Secondary,  128.  Of  capsule  of 
sessile  cyst,  227.  Cure  of  ovarian 
cyst  by,  its  futility,  181.  Of  cyst 
in  incomplete  ovariotomy,  230. 
After  ovariotomy,  242,  474.  After 
vaginal  extirpation  of  uterus,  324. 

Drainage-tube,  125,  474.  India-rubber, 
129.  India-rubber  cloth  for,  129. 
Keith's,  126.  Koeberle's,  125. 
Nussbaum's  case  of  escape  of,  from 
abdominal  cavity,  266. 


Duckbill  speculum.  See  Sims'  specu- 
lum. 

Duncan,  Dr.  .J.  ilatthews  :  On  atresia, 
9,  459,  460,  462,  463,  468.  On 
laceration  of  cervix,  339.  On 
])atency  of  the  Fallopian  tube,  24. 
On  the  labia  majora,  1.  On  ethi- 
cal aspect  of  an  operation,  276. 
On  the  perineum,  389  note,  405. 
On  danger  of  cutting  off  a  fibroid 
polypus,  304.  On  absence  of  ped- 
icle in  purely  intra-uterine  polypi, 
307.  On  hiBmorrhage  from  pedi- 
cle of  fibroid  polypi,  306.  On 
uterine  contractions  and  expan- 
sions, 17  note.  On  dissection  of  an 
artificial  vagina,  466.  On  vesical 
systole,  30  note.  On  laceration  of 
vestibule  during  labour,  11. 

Duncan,  Dr.  William,  on  total  extir- 
pation of  the  uterus,  318,  323,  324. 

Dyspareunia  :  In  chronic  inflammation 
of  appendages,  275.  In  vesico- 
vaginal fistula,  421. 


E 


Ecraseur  chain,  329.  In  cancer  of 
cervix,  328.  In  elongation  of 
cervix,  335. 

Ecraseur,  galvanic,  152.  See  Galvano- 
cautery. 

Ectopia  vesicae,  449.  "Wood's  opera- 
tion for,  451. 

EctropioJi  in  laceration  of  cervix : 
Treatment  ot  before  ti-achelorrha- 
phy,  340.  Modification  of  trache- 
lorrhaphy in  extreme,  346. 

Electrical  apparatus  in  gynpecological 
surgery,  141. 

Electrolysis  apparatus,  141.  In  cancer 
of  the  cervix,  333. 

Elytrorrhaphy  or  colporrhaphy,  406. 
Dieflenbach's,  407.  Emmet's,  409. 
Lefort's,  412.  Neugebauer's,  412. 
Simon's,  412.  Sims',  407.  Gail- 
lard  Thomas's,  412. 

Embolism  after  ovariotomy,  267. 

Emmet,  Dr.  T.  A. :  His  elvtrorrhaphy, 
409.  On  trachelorrhaphy,  339. 
His  operation,  340.  On  sjjontan- 
eous  cure  of  vesico-vaginal  fistula, 
424. 

Emmet's  operation.  See  Trache- 
lorrliapliy. 

Emplastrum  resinre  for  waterproof 
sheet,  87. 

Encapsuled  ovarian  cysts,  225. 


478 


INDEX. 


Endometrium,  19. 

Enemata  after  ovariotomy,  248.     Beef 

tea,  after  ovaiiotomy,  245. 
Entero-vaginal  fistula,  448. 
Enucleation  :  Of  ovarian  tumour,  226. 
Of  uterine  fibroid  during  hj'ster- 
ectomj^,    293.      Of    intra-uterine 
fibroid,  307. 
Episiorrhaphy,  405. 
Epispadias,  4^48. 
Examination,    methods   of  pelvic,  45. 

Of  abdominal  tumours,  168. 
Exploratory  puncture  of  ovarian  cysts, 

177. 
Extirpation  of  uterus,  abdominal,  318 

note.  Vaginal,  318. 
Extra-uterinepregnancy,  350.  Varieties 
of,  351.  Abdominal,  352. 
Ovarian,  352.  Tubal,  351. 
—  Treatment  of :  Active,  353.  By 
electricity,  354.  Extirpation 
of  sac  at  time  of  rupture,  357. 
"NVhen  unruptured  before  and 
after  term,  365.  Incision  of 
ruptured  sac,  361.  Of  un- 
Tuptured  sac,  362.  By  injec- 
tion of  chemicals,  353.  Pallia- 
tive, 353.  Puncture  of  sac, 
353.  Vaginal  section,  354. 
Exti-oversion  of  bladder.  See  Ectojna 
vesiccc. 


F 


Fsecal  fistula,  446.  After  ovariotomy, 
265. 

Fallopian  tubes,  22.  Accessory  fimbrife 
of,  25.  Canal  of,  17,  24,  25,  75. 
Fimbriae  of,  24.  Inflammation  of, 
273.     Papilloma  of,  163. 

Fascia,  pelvic,  36. 

Fergusson's  speculum,  58. 

Fibroid  polypus,  uterine :  Excision 
of,  303.  Fatal  case,  304.  Ligature 
of,  306.  Removal  of,  by  ecraseur, 
306. 

Fibroid,  uterine  submucous  :  Enu- 
cleation of,  307.  Matthews  Dun- 
can on,  307  note.  Incision  of 
capsule  of,  312. 

Fibroid,  uterine  subperitoneal,  300. 
Danger  of  removing  small,  during 
ovariotomy,  232. 

Fibroid,  uterine  tumour,  286.  Opera- 
tions for  relief  of:  see  Hysterectomy, 
Oophorectomy,  and  Fo/to's  opera- 
tion. 

Fibro-myoma  of  uterus,  286. 


Fll-de-Florencc,  120 

Fimbriae,  accessory,  of  Fallopian  tubes, 
25. 

Fistula,  fiecal,  after  ovariotomy,  265. 

Fitch,  his  dome-trocar,  105. 

Fixateur  or  tampon-screw,  Sims',  311. 

Flushing  the  peritoneum,  204,  236. 

Foitation,  extra-uterine.  See  Extra- 
uterine preg/iancy. 

Forcipressure,  93. 

Forceps  :  Artery,  93, 

—  Clamp,   112. 

—  Large  pressure,  or  cyst-forceps, 

109. 

—  Large     pressure  :     In    securing 

ovarian     pedicle,      219.       In 
oophorectomy,  280. 

—  Pressure,  Koeberle's,  94  ;  Peau's, 

95  ;   Tait's,    99  ;    Wells'    old 
form,  96  ;  Wells'  new,  97. 

—  Speculum,  60  ;   T-bladed,  100. 
Fornix,  anterior  vaginal,  13. 
Fornix,  posterior  vaginal  or  posterior 

cul-de-sac,  14.  In  digital  ex- 
ploration, 52. 

Fossa  navieularis,  3. 

Fourchette,  posterior,  2. 

Frasnulum,  2. 

Freund,  his  operation,  318  note.  On 
extra-uterine  pregnancy,  351,  352. 

Fristo's  case  of  abnormal  vaginal  septa, 
7. 

Fused  ovarian  cysts  with  ilouble 
pedicles,  216,  225. 


G 


6alvanic  ecraseur,  152. 

Galvano-cautery,  141.  Advantages  and 
disadvantages  of,  155.  Battery, 
144.  Amputation  of  cervix  by,  325, 
335.  For  incision  of  extra-uterine 
gestation  sac,  356. 

Gangrene  of  ovarian  cyst,  operation 
for,  176. 

Garrigues,  Dr.  :  On  the  course  of  the 
ureters,  31.  On  Ctesarean  section, 
370. 

Gauze,  absorbent,  how  to  test,  131. 

Genupectoral  position,  57. 

Gestation,  extra  uterine.  See  Extra- 
uterine ^jj-cf/^iaTicy,  Tubal  jn'cg- 
nancy,  etc. 

Godson,  Dr.  Clement :  Case  of  Porro's 
operation,  379. 

Goodell,  Dr.,  on  parotitis  after  trache- 
lorrhaphy, 346. 

Grove's  battery,  148. 


INDEX. 


479 


H 


Hsematosalpinx,  274. 

Handcuffs  for  ovariotomy,  86. 

Hart,  Dr.  Berry,  his  suggestion  for 
testing  tliickness  of  pedicle  of 
uterine  polypus,  305. 

Hart,  and  Barbour  :  On  Alexander's 
operation,  413.  On  operation  for 
atresia,  463.  On  the  genupec- 
toral  position,  57.  On  the  vaginal 
walls,  15. 

Hegar,  Professor  :  His  amputation  of 
the  elongated  cervix,  £37.  Case 
of  passage  of  ovarian  pedicle  into 
the  rectum,  266.  His  spiral 
incision  of  fibroid  polypus,  305. 

Hermaphroditic  malformations  in 
ectopia  vesicae,  450. 

Hernia  of  ?,bdominal  cicatrix  after 
ovariotomy,  253. 

Hilum  of  ovary,  26. 

Holmes,  Mr.  Timothy  :  Operation  for 
ectopia  vesicas,  451. 

Hot  water  as  a  haemostatic,   204  note. 

Hot  water  :  Washing  out  peritoneal 
cavity  with,  204,  236.  Precau- 
tions in  applying  waterproof  sheet 
before,  88. 

Hydatid  of  Morgagni,  168. 

Hydrosalpinx,  274. 

Hymen,  4.  In  atresia,  9,  458,  462. 
Absence  of,  8.  Laceration  of,  8. 
Present  in  some  forms  of  atresia, 
462.  Varieties  and  abnormalities 
of,  6,  458. 

Hyperpyrexia  after  ovariotomy,  258. 

Hysterectomy,  supra-vaginal,  287. 
Management  of  pedicle  in,  292, 
297.  For  rapture  of  pregnant 
uterus,  386.  See  also  Porro- 
FreuncVs  ojjerahon,  Porro's  opera- 
tion, and  Vaginal  extirjMtion  of 
uterus. 

Hysterorrhaph}^,  405,  413. 


I 


Ice-bladders,  137. 
Ice-cap,  Thornton's,  133. 
Imperforate  hymen.     See  Atresia. 
Incision   and    drainage  :     Futility   of 

attempting  cure  of  ovarian  cysts 

by,  181.     Of  sac  in  extra-uterine 

pregnane}',  361. 
Incomplete  ovariotomy,  228. 
India-rubber  cloth  for  drainage-tube, 

128. 


India-rubber  drainage-tube,  129. 

Infundibulo-pelvic  ligament,  27,  35, 
37,  38.     In  ovariotomy,  219. 

Inspection,  pelvic,  45. 

Insufflator,  Clay's  uterine,  138.  Kab- 
iersky's,  138,  298. 

"  Interstitial,"  or  tubo-uterine  preg- 
nancy, 361. 

Irremovable  base  of  ovarian  cyst,  227. 


Kabiersky's  insufflator,  138,  298. 

Keetley,  Mr.,  on  hot  water  as  a  hemo- 
static, 204,  237. 

Kehrer,  his  incision  in  Csesareau  sec- 
tion, 378. 

Keith,  Dr.  T.  :  His  drainage-tube,  126. 
•  His  note  on  a  case  of  faical  fistula 
after  ovariotomy,  265.  On  tapping 
broad  ligament  cysts,  180. 

Kelly,  Dr.  Howard,  on  hysterorrhaphy, 
413  7iote. 

Key's  director,  102. 

Kidd's  volsella,  309. 

Kolpokleisis,  442. 

Knot :  For  ligature  of  ovarian  pedicle, 
221  note.  For  abdominal  sutures, 
239. 

Koeberle's  drainage-tube,  125.  Pres- 
sure-forceps, 94.  Serre  -  nceud, 
122,  295,  299,  302,  367. 

Krassowsky,  cases  of  tetanus  during 
ovariotomy,  269. 

Kystes  lacimeuo:  of  Verneuil  :  Their 
appearance  in  hysterectomy,  291. 


Labia  :  Majora,  1;  Minora,  3.    Removal 

of  tumoui's  of,  468. 
Laminaria  tents,  79. 
Lamp,  electric,  156. 
Laparo-elytrotomy,  386.     Relations  of 

ureters  most  important  in,  33. 
Large  pressure-forceps  or  cj'st-forceps, 

109.     In  oophorectomy,  280. 
Lefort's  elytrorrhaphy,  412. 
Leiter's  tube,    cap,    and    temperature 

regulator,  135. 
Leopold,  statistics  of  Csesarean  section, 

375.     And   Sanger,   their  method 

of  closing  the  uterine  wound  after 

Caesarean  section,  373. 
Levator  ani,  48. 
Ligament.        See      Broad'     ligament. 

Ovarian  ligament,  etc. 


480 


INDEX. 


Ligatiii'e  of  ovarian  pedicle,  pathology 
of,  185.     See  Pedicle,  Ovariccn. 

Lowe,  Dr.  "Walter  ;  Case  of  extra- 
uterine pregnancy,  360. 

Lusk,  Dr.  :  On  Cesarean  section,  373. 
On  gastrotoniy  for  rupture  of  the 
uterus,  379.  On  laparo-elytrotomy, 
or  Thomas's  operation,  386. 

Lvniphatica,  pelvic,  44. 

Lyon,  Dr.,  case  of  f?ecal  fistula,  265. 


.M 


^[aekintosh    apron,    197.      Sheet    for 

ovariotomy,  87,  198. 
^larckwald's  amputation  of  the   elon- 
gated cem'ix,  337. 
Matthieu's  catch,  96,  107. 
Meatus  urinarius,  11. 
Menstruation  after  ovariotomy,  270. 
Meso-salpinx,  35. 
Mirror  for  abdominal  sections,  87. 
Milk  diet  and  scybala,  244,  398. 
Morphine    or    morphia    (see    Opium), 

injections     of,     in      extra-uterine 

gestation  sac,  353. 
Munde,  Dr.,  on  Alexander's  operation, 

417. 
Muscles,   pelvic,   36.     As  detected  on 

digital  exploration  of  the  vagina, 

48. 
Myoma,      286.       See      Hijstcrcdomy, 

Fibroid  Polypus,  etc. 


iN" 


Xeedles,  pedicle,  112.   Hagedorn's,  117. 

Used    for   sutures   in  ovariotomy, 

116. 
Xeedle-holder,  115,  233.     Hagedorn's, 

118. 
Xelaton's  volsella,  107. 
Xerves,  pelvic,    37.     Pressed  upon   in 

pelvic  exploration,  37,  49. 
Xeugeliauer's     speculum,      64.        His 

elytrorrhaphy,  412. 
Nightmare  after  ovariotomy,  268. 
Nomenclature  of  instruments,  82. 
Note-book,  ovariotomy,  167,  192,  270. 
Nurse  for  ovariotomy,  1 90. 
Nussbaum  :    Singular  case  of  escape  of 

drainage-tube      from      abdominal 

cavity,  266. 
Nymphje,  3. 


O 


Obturator  internus,  49. 

Ohm,  143. 

Olshausen  :     On  cause  of  tetanus  after 

ovariotomy,  269. 
Oophorectomy,  272.     When  justifiable, 
276.     For  disease  of  the  append 
ages,  277.     For  fibroid  of  uterus, 
283.     For  relief  of  neuroses,  272, 
282. 
Operating  table  for  ovariotomy,  189. 
Opium  :  After  ovariotomy,  244.     After 
plastic  operations  on  the  perineum, 
398. 
Ovarian  artery,  37, 38.    Fluid,  receptacle 
for,   during  operation,   85.     Liga- 
ment, 18,  26.     Pregnancy,  352. 
Ovariotomy  :  Abdominal  wound.     See 
Abdominal  wound  in  ovariotoimj. 
Abscess   after,    266.       Adhesions, 
abdominal,    management  of,  212  ; 
pelvic,  management  of,  216.     Age 
of  patient,  182.     Ague  after,  258. 
Apartment  for  patient  after,  187. 
Assistants,  199.     Bed  for  jiatient, 
189.   Bed-sores  after,  247.   Bladder, 
catheterism    of,    after,    250 ;     in- 
fiainmation  of,  after,  256.     Bowels, 
opening  after,   247.     Cautery  in, 
185.     Catheterism  after,  250.     Ci- 
catrix.    See  Abdominal  uvicyul  in 
ovariutomy.        Clamp      in,      185. 
Cleaning    the    peritoneal    cavity, 
236.    Closure  of  abdominal  wound, 
239.     Clothing  of  patient  during, 
194.    Counting  sponges  and  instru- 
ments,   237.     Cystitis  aftei',    256. 
Diarrhcea  after,   256.     Diet  a^ter, 
243.       Drainage,    126,    242,    474. 
Dressing  abdominal   wound,   240 
Embolism,  pulmonary,  after,  267 
Enemata     after,    248  ;     nutrient, 
after,  245.     Enucleation  of  a  cyst, 
226.    Exploration  of  ovary  oi)posite 
the  tumour,  230.      Extraction  of 
cyst,  208.     Flatulence  after,  relief 
of,    256.     Foreign    bodies   left  in 
abdominal  cavit}-  after,  265.     Gas- 
tric disturbance  after,  255.    Hsenia- 
tocele    of  the   pedicle  after,    270. 
Haunorrhage,  internal,  after,  262. 
Hernia  of  cicatrix  after,  254.     In- 
complete,   228.     Li   infancy,   182. 
Instruments  recjuired  for :  Arrange- 
ment of,  197  ;    list  of,  196  ;    clean- 
ing,   after,     85,     243.       See    also 
Scissors,    2'roear,    etc.     Intestinal 
irritation   after,    256.       Intestinal 


INDEX. 


481 


olistniction  after,  264.  Ligature 
of  pedicle,  185,  218.  Menstruation 
after,  270.  Nightmare  after,  268. 
Note-book  and  notes  for  eases  of, 
167,  192,  270.  Nurse,  190.  Nu- 
trient enemata  after,  245.  Oper- 
ating table  for,  189.  Opium  after, 
244.  Palpitations  after,  268. 
Parotitis  after,  267.  Pedicle  :  See 
Pedicle,  Ovarian.  Phlegmasia 
after,  266.  Position  of  operator 
and  others  during,  199.  In  preg- 
nancy, 184.  Purgatives  :  Before 
operation,  194  ;  danger  of  ad- 
ministering them  Avithin  a  few 
hours  of  the  operation,  194,  256  ; 
after  ovariotomy,  248.  Pysemia 
after,  259.  Septicemia  after,  259. 
Solid  matter  and  secondary  cysts, 
breaking  down,  209.  Sj^onges  and 
instruments  left  in  peritoneal 
cavity  after,  238.  Steps  of  the 
operation,  195.  Sutures :  Intro- 
duction of,  into  abdominal  wound, 
2-34.  Removal  of,  251.  Syncope 
from  antemia  of  the  brain  after, 
268.  Temperature,  rise  of,  after, 
258.  Tetanus  after,  268.  Throm- 
bosis after,  266.  Treatment  before, 
193.  Trocar :  See  Trocar,  Ovari- 
otomy. Vomiting  after,  243,  255, 
256,  260. 

Ovar}',  26.  Surgical  pathology  of  cystic 
disease  of,  158.  Inflammation  of, 
274. 

Owen,  Mr.  Edmund,  on  atresia  in 
infants,  459. 


Paget,  Mr.  Stephen,  on  parotitis,  after 

ovariotomy,  267. 
Pallen,    Dr.    Montrose,    on    trachelor- 
rhaphy in  childbed,  346. 
Palpation  :     Abdominal,       Bimanual, 

53. 
Pampiniform  plexus,  37,  43. 
Pancoast  :    Operation  for  ectopia  vesi- 

Cffi,  451. 
Papilloma  :  Of  broad  ligament,  162.  Of 

Fallopian  tube,   163.      Of    ovary, 

161. 
Paquelin's  cautery.     See   Thcrmo-cau- 

tcnj. 
Parker,  Mr.  E.  W.  :   The  supra-pubic 

operation    for  I'emoval   of  vesical 

tumours,  473. 
Parotitis  :  After  ovariotomy,  267.  After 

trachelorrhaphy,  345. 


Parovarian  cysts.  See  Broad  ligaincnt 
cysts,  simple. 

Parovarium,  27. 

Parvin,  Dr.,  case  of  uretero-vaginal 
fistula,  441. 

Pawlik,    Dr.,    on   amputation    of    the 
cervix  uteri,  327. 

Pean's  forceps,  95. 

Pedicle  needles,  112. 

—      pins  (for  hysterectomy),  124. 

Pedicle,  in  hysterectomy,  292, 

Pedicle,  ovarian,  215.  Changes,  morbid, 
in,  266.  Detachment,  spontane- 
ous, of,discovered  during  operation, 
177,  211,  217.  Double,  in  fused 
ovarian  cysts,  216,  225.  Ha-ma- 
tocele  of,  270.  Ligature  of,  185, 
215,  218.  Slipping  of,  from  liga- 
ture, 262.  Splitting  of,  186,  262. 
Stump  of,  passed  at  stool,  266. 
Transfixion  of,  220.  Twisting  of, 
177.  See  also  Sessile  tumours  and 
Ute7-inc  tissue. 

Pedicle  of  pedunculated  uterine  fibroids, 
302.  Of  fibroid  uterine  polypi, 
305.  Of  mucous  uterine  polypi, 
314. 

Pelvic  arteries,  etc.  See  Arteries  of  the 
pelvis  and  Artery. 

Perineorrhaphy  :  For  relief  of  pro- 
lapsus, 405.  See  Ferineum,  rup- 
ture  of. 

Perineum  :  Anatomy  of,  388.  Ruptiire 
of,  387.  Operation  for  repair  of 
(perineorrhaphy),  391.  Bantock's 
method,  392.  Purse-string  opera- 
tion, 399.  Pathology  of,  389. 
Partial  rupture  of,  402. 

Peritoneum -hook,  Adams',  101,  203. 

Peritoneum  :  Pelvic,  33.  Uterine,  20, 
34.  "Toilet,"  236.  Cleaning  or 
washing  out,  or  flushing  Avith 
Avater,  204,  236. 

Peritonitis  after  ovariotomy,  259. 

Phlegmasia  after  ovariotomy,  266. 

Pigmentary  line  along  linea  alba,  202. 

Pins  :  For  uterine  pedicle,  124.  In  h3-s- 
terectomy,  295. 

Placenta,  AA'ounds  of,  in  operations  on 
pregnant  uteri  and  extra-uterine 
foetal  sacs,  364,  372. 

Platinum  knife,  for  galvano-cautery, 
151. 

Playfair,  Dr.,  on  trachelorr]ia])hy,  339. 
On  laparo-elytrotomy,  or  Thomas's 
operation,  386. 

Plexuses  :  Pampiniform,  43.  Venous, 
41. 

Plugging  the  vagina,  61. 

I  r 


482 


INDEX. 


Polarization,  146. 

Polypus- forceps,  uterine,  314. 

Polypus,  uterine  fibroid.  See  Fibroid 
polypus,  utei'inc. 

Polypus,  uterine  mucous  :  Removal 
of,  313.     Fatal  case,  315. 

Porro's  operation  :  Dr.  Godson's  defi- 
nition of,  379.  Details  of  the 
operation,  380.  Allied  operations  : 
Porro-Freund's,3S2.  Supra -vagirial 
hysterectomy  during  pregnancy, 
384.  After  rupture  of  the  uterus, 
378,  386. 

Porro-Freund's  operation,  382. 

Pouch  of  Douglas.  See  Douglas's 
2)ouch. 

Pregnancy  :  Discoloration  of  vidva  in, 
3,  46.  Extra-uterine  :  See  Extra- 
uterine pregnancy.  Hysterectomy 
during,  384.  Ovariotomy  during, 
184.  See  Cccsarean  section  aiul 
Porro's  operation. 

Pregnant  fibroid  uterus  :  Operations  on, 
384.     Removal  of,  at  term,  385. 

Pressure-forceps,  93.     See  Forceps. 

Prolapse  of  vaginal  walls  and  uterus, 
operations  "for,  404.  Its  relation 
to  hernia,  407. 

Puech  on  retained  menstrual  blood,  460. 

Purgatives  and  aperients  after  ovari- 
otomy, 248. 

Pytemia  after  ovariotomy,  260. 

Pye,  Mr.  "Walter :  The  supra-pubic 
operation  for  removal  of  vesical 
growths,  473. 

Pyosalpinx,  274. 

Pyriforniis,  49. 


R 


Receptacle    for   ovarian    fluid    during 

operation,  85. 
Rectal  examination,  69.     By  introduc- 
tion of  entire  hand,  70. 
Recto-abdomiual  examination,  71,  462, 

466. 
Recto-vaginal  examination,  72. 
Recto-vaginal  fistula,   446.    Operation 

for,  447. 
Recto-vesical     examination,    72,    462, 

466. 
Reef-knot,  double,  221  note. 
Resin    ]iJaster   for   waterproof    sheet  : 

How  to  prepare,  87. 
Rheophore,  149. 
Rheostat,  145. 
Roberts,  Dr.  Carr  :  Caseoftubo-nterine 

pregnancy  361. 


Robson,  lilr.  IMayo  :  Case  of  atresia 
with  distension  of  Fallopian  tubes, 
462.  Operation  for  ectopia  vesicae, 
451. 

Round  ligaments,  18.  Alexander's 
operation  on,  413. 

Routh,  Dr.  C.  H.  F.  :  Case  of  extra- 
uterine pregnancy,  356.  On  the 
treatment  of  rupture  of  uterus, 
377. 


S 


Sanger,  Professor :  His  modification 
of  Cesarean  section,  370.  Rules 
for  simplification  of  same,  375. 

Sarcoma  of  ovary,  164.  See  Solid 
ovarian  tumours. 

Savage,  Dr.  Henry  :  Ou  the  Fallopian 
tube,  25.  On  the  perineal  body, 
388.  On  the  vestibular  glands, 
11. 

Scalpel,  for  abdominal  sections,  91. 

Schroder :  His  method  of  supra- 
vaginal excision  of  the  cervix, 
330.  Of  excision  of  cervix  and 
use  of  caustics,  382.  Of  amputa- 
tion of  the  elongated  cervix,  335, 
.337. 

Scissors,  for  ovai'iotomy,  92. 

Scybala  and  milk  diet,  244. 

Screw,  Tait's,  287,  290. 

Semi-prone  position,  57,  63. 

Septa,  abnormal,  in  vagina,  7. 

Septicemia  after  ovariotomy,  259. 

Sessile  ovarian  tumours,  211,  225. 

Serre-nceud,  122.  Cintrat's,  124.  See 
Kocherles  Scrre-nceud. 

Sheet,  waterjiroof,  for  ovariotomy,  87. 

Shively  Dr.  :  His  case  of  intestinal 
obstruction  six  years  after  ovari- 
otomv,  264 

Silk,  for  ligature,  119. 

Silkworm-gut,  120,  239. 

Simon,  Professor  :  His  amputation  of 
the  elongated  cervix,  337.  His 
dilator,  472.  His  elytrorrhaphy, 
412.  His  case  of  atresia  of  urethra 
between  two  fistul;^,  438.  His 
principle  in  operations  for  vesico- 
vaginal fistula,  426. 

Simpson's  volsella,  308  note. 

Simpson,  Dr.  A.  R.  :  His  method  of 
vaginal  extirpation  of  the  uteru.s, 
322.  Of  amputation  of  the  elon- 
gated cervix,  338. 

Sims,  Dr.  Marion  :  Treatment  of  can- 
cerous cervix,  332.    Of  elongated 


INDEX. 


483 


cervix,  336.  Elytrorrliapliy,  407. 
Guarded  tumour-hook,  309.  Specu- 
lum, 62.  Tampon-screw  or  fixa- 
teur,  310.  Principles  of  operation 
for  vesico-vaginal  fistula,  426. 

Skene's  tubes,  12. 

Smart,  Dr.  David,  and  Freund,  on 
extra-uterine  gestation,  351. 

Solid  ovarian  tumours,  164.  Abdom- 
inal incision  in  removal  of,  185. 

Sound,  uterine,  73.  How  to  introduce, 
74. 

Spanton,  Mr.,  on  fcetal  bone  left  in 
gestation  sac,  364. 

Specula,  relative  merits  of  different 
kinds,  68. 

Speculum-forceps,  60. 

Speculum,  58.  Barnes',  65.  Boulton's, 
for  trachelorrhaphy,  341.  Boze- 
man's,  62.  Cusco's,  67.  Fer- 
gusson's,  59.  Neugebauer's,  64. 
Sims',  62.     Valvular,  64. 

Sphincter  vaginse,  48. 

Sponge-holder,  427.  ^ 

Sponge-tents,  79. 

Sponges,  89.  Cleaning  and  counting 
after  abdominal  section,  90,  237. 
In  ovariotomy,  196,  237.  Prepar- 
ation of  new,  89. 

Stanley's  director,  102,  204. 

Staude,  Dr.  :  His  method  of  vaginal 
extirpation  of  uterus,  324. 

Straps  for  ovariotomy,  86. 

Subperitoneal  uterine  fibroid,  removal 
of,  300. 

Surgeon's  knot,  221  note. 

Sutiires  for  ovariotomy,  119.  Arrange- 
ment of,  after  introduction,  236. 
Introduction  of,  232.  Needle  for, 
116.  Removal  of,  251.  Accident- 
ally passed  through  intestine,  264, 
265.     Silkworm-gut.  120. 

Suture-twister,  S-headed,  432. 


Table,  operacing,  for  ovariotomy,  189. 

Tait,  Mr.  Lawson  :  On  Alexander's 
operation,  417.  On  extra-uterine 
pregnancy,  352.  On  extirpation 
of  ruptured  fcetal  sac,  357.  On 
opium  after  perineorrhaphy,  398. 
Ovariotomy  trocar,  104.  On  wash- 
ing out  peritoneum,  204,  236. 
Pressure-forceps,  99.  Screw  for 
extracting  uterine  fibroid,  287, 
290. 

Tampon-screw,  Sims',  310. 


Tangle-tents,  79. 

Tapping  ovarian  cysts,  177.  During 
ovariotomy,  207,  231. 

T-bladed  pressure-forceps,  100,  111. 

Teale's,  Mr.  Pridgin,  Danrjcrs  to  Hccdth, 
189. 

Temperature,  rise  of,  after  ovariotomy, 
258. 

Tents,  79.  Disinfection  of,  81.  Intro- 
duction of,  80.     Removal  of,  81. 

Tetanus  after  ovariotomj',  268. 

Thermo-cautery :  Paquelin's  com- 
pared with  galvano-cautery,  155. 
In  atresia,  463.  In  incision  of 
capsule  of  submucous  uterine 
fibroid,  312.  In  vaginal  section 
of  extra-uterine  gestation  sac,  356. 

Thomas,  Dr.  Gaillard :  On  elytror- 
rhaphy,  407,412.  On  the  galvano- 
cautery  in  elongation  of  the  cervix, 
335.  Laparo-elytrotomy,  386.  On 
partial  rupture  of  the  perineum, 
402.  On  Sims'  amputation  of  the 
elongated  cervix,  336.  Chronic 
tetanus  after  ovariotomy,  269.  On 
uretero-uterine  fistula,  442. 

Thompson,  Sir  Henry :  Supra-pubic 
operation  for  I'emoval  of  vesical 
growths,  473. 

Thorburn,  Dr.  :  On  the  galvano-cautery 
in  elongation  of  the  cervix,  335. 
On  the  speculum  in  recto-vaginal 
fistula,  448. 

Thornton,  Mr.  J.  Knowsley  :  Ice-cap, 
133.  Excision  of  a  hernial  pouch 
formed  in  abdominal  cicatrix,  255. 
Ligature  of  pedicle  in  an8eniic 
patients,  219.  Intestinal  obstruc- 
tion :  His  therapeutic  treatment  of, 
265.  Listerian  dressing  of  wound, 
240.  Ovariotomies  m  cases  ^\here 
incision  and  drainage  had  failed, 
181.  Degenerate  placenta  in  extra- 
uterine pregnancy,  367.  On  (|ui- 
nine  in  beef-tea  enemata,  247. 
Removal  of  pregnant  filiroid  uterus, 
385. 

Thrombosis  after  ovariotoni}',  266. 

Tilt's,  Dr.,  To2iche7;  or  recto-vaginal 
examination,  72. 

"  Toilet  of  the  peritoneum,"  236. 

Touclicr,  or  recto-vagiiuxl  examination, 
72. 

Trachelorrhaphy,  or  Emmet's  operation, 
340.  Palleu's  "immediate,"  346. 
Parotitis  after,  345. 

Trask,  Dr.,  on  seat  of  rupture  of  preg- 
nant and  parturient  uterus,  379. 

Trays  for  instruments,  83. 


48 1 


INDEX. 


Trocar,  dome,  103  note. 

Trocar  :  Ovariotomy,  102.     Tait's,  104. 

Wells',  102. 
Ti-ocar,  tai)piiig,  105,  179,  231. 
Tubal  prei^uaucy  or  gestation,  351. 
Tubes.      See   Fallojjian  tubes,   Skene's 

tubes,  etc. 
Tupelo-tents,  79. 
Twisting  of  pedicle,  177. 


U 


Umbilicus  :  Removal  of  its  tissues  to 
facilitate  union  of  abdominal 
wound,  185,  289. 

Ilraclius,  202. 

Uretero-vaginal  and  uretero-uterine 
iistula,   422,   441. 

Ureters,  31,  Relation  of  artery  of 
cervix  to,  43. 

Urethra:  Atresiaof,  complicatingvesico- 
vaginal  fistula,  437.  Dilatation  of, 
472.  Meatus  of,  11.  As  felt 
through  vaginal  Avail,  50.  Car- 
uncle or  vascular  tumour  of,  its 
removal,  469- 

Uterine  artery,  39.  In  hysterectomy, 
297.  In  siipra-vaginal  excision  of 
cervix,  331.  In  vaginal  extirpation 
of  uterus,  321. 

Uterine  insufflator,  Clay's  and  Kabier- 
sky's,  138. 

Uterine  tissue :  Unsafe  for  ligature, 
17,  222.  Sometimes  included  in 
ovarian  pedicle,  39,  222,  227. 

Utero-sacral  ligaments,  19. 

Utero-vesical  ligaments,  19. 

Uterus.  Anatomy  of,  16.  Circular 
venous  sinus  of,  371,  378.  See 
Cervix  uteri. 

Uterus :  diseases  of  and  operations 
upon.  See  Fibroid,  uterine ;  Fi- 
broid 2}oliipus,  uterine  ;  Polyjjus, 
uterine  mucutis  :  Hysterectomy ; 
Vaginal  extirpation  of  %itenis,  etc. 

Urethral  or  urethro-vaginal  fistula,  437. 

Urinary  fistula,  418. 

U-teeth,  in  blades  of  pressure-forceps, 
98. 


Vagina,  12.  Deficiency  of,  465.  Ex- 
ploration of,  46,  53,  57.  Plugging 
of,  61.  Operations  for  prolapse  of, 
404    406. 


Vaginal  dilator,  elastic  gum,  425. 

Vaginal  extirpation  of  uterus,  318. 

Vaginal  septa,  abnormal,  7. 

Valvular  speculum,  64. 

Vascular  tumour  of  urethra,  or  urethi'al 
caruncle,  469. 

Veins,  pelvic,  41. 

Vesico-rectal  examination,  72,  462, 
466. 

Vesico-uterine  fistula,  440. 

Vesico-uterine  pouch,  33. 

Vesico-vaginal  fistula,  418.  Operation 
for  relief  of,  426.  Operation  in 
cases  of,  near  cervix  uteri,  436. 
Colpoeleisis  for  extreme  cases  of, 
444. 

Vessels,  pelvic,  37. 

Vestibule,  11. 

Volsella :  For  diagnosis,  58,  69,  71, 
76,  78.  For  ovariotomy,  106. 
For  removal  of  fibroid  polypi  — 
Nekton's,  107.  Kidd's,  309. 
Simpson's,  308  note. 

Volt,  142. 

Vomiting  after  ovariotomy  :  From  the 
aniesthetic,  243,  255.  From  septic 
conditions,  260.  From  gastro- 
intestinal disturbance,  256. 

V-teeth,  in  blades  of  pressure-forceps, 
99. 

Vulselluni.  See  Volsella,  and  page  76 
note. 


W 


Washing  out  peritoneal  cavity,  204, 
236. 

Watson,  Professor,  on  the  ureters, 
33. 

Waterproof  apron,  for  operator  and 
assistants,  197. 

AVaterproof-sheet  :  For  drainage-tube, 
128.  For  ovariotomy,  etc.,  87, 
198.  Not  needed  in  oophorec- 
tomy, 277. 

Wells,  Sir  T.  Spencer  :  Clamp-forceps, 
112.  Forcipressure,  93.  Ovari- 
otomy-trocar, 102.  Pedicle-liga- 
ture in  ovariotomjs  the  knot  for, 
221  note ;  the  tightness  of,  222 
note.  Pedicle-needle,  114.  Porro- 
Freund's  operation,  382.  Porro's 
operation  in  case  of  fibroid  uterus, 
385.  Pressure-forceps  :  Old  form, 
96.     New  form,  97. 

Wet-packing  after  ovariotomy,  259. 


INDEX. 


485 


Wire-loop.     See  KochcrU's  serre-nceud. 

"Williams,  Dr.  John  :  On  the  vascular 
supply  of  the  uterus,  40.  On 
recurrence  of  uterine  cancer,  317. 
His  adoption  of  Sanger's  method 
of  supra-vaginal  excision  of  the 
cervix,  331  note. 

Wood,  Mr.  John  :  Operation  for  ecto- 
pia vesicce,  451. 

Womb.     See  Uterus. 

Wool,  absorbent,  how  to  test,  131. 


Wristlets  or  handcufts  for  ovariotomy, 

86. 
Wylie,   Dr.  Gill  :    On  hot  water  as  a. 

preventive  of  .shock,  204  note. 


Zweifel,  Professor  :  Removal  of  kidney 
in  ureteric  fistula,  442. 


OCTOBER,  1887. 
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Sutton.     Volumetric  Anal.        5.00 

Thompson's  Physics.     -         

Trimble.     Analytical.      -  1.50 

Vacher's  Primer  of.  -  .50 

Valentin.     Quale.  Analy.  3.00 

Ward's  Compend.   -        -  i.oo 

Watts.     (Fowne's)  Inorg.         2.25 

(Fowne's)  Organ.  2.25 

Wolff.  Applied  Medical  Chem- 
istry.       .        .        -        .  1.50 

CHILDREN. 
Chavasse.    Mental  Culture  of.  i.oo 
Day.     Diseases  of.  -        -  3.00 

Dillnberger.    Women  and.      1.50 
Ellis.    Mother's  book  on.  .75 

Goodhart  and  Starr.  3  00;  Sh.  3.50 
Hale.     Care  of.         -        -  .75 

Hillier.     Diseases  of.       -  1.25 

Meigs.      Infant  Feeding    and 

Milk  Analysis.         -        -  i.oo 

Meigs  and  Pepper's  Treatise. 5. 00 
Money.     Toeaiment  of.  -  3.00 

Smith.    Wasting  Diseases  of.  3.00 

Clinical  Studies.  -  2.50 

Starr,  Digestive  Organs  of.       2.50 


COMPENDS 
And  The  Quiz-Compends. 
Brubaker's  Physiol.  3d  Ed.  Jd. 00 
Kox  and  Gould.  The  Eye.  i.oo 
Horwitz.  Surgery.  3d  Ed.  i.oo 
Hughes.  Practice.  2  Pts.  Ea.  i.oo 
Landis.  Obstetrics.  3d  Ed.  i.oo 
Leffmann's  Chemistry.  i.oo 

Mason.     Electricity.       -  i.oo 

Potter's   Anatomy,   including 
Visceral  Anatomy.   117  lUus.  i.oo 

Materia  Medica.  4th  Ed.  i.oc 

Roberts.  Mat.  Med.  and  Phar.  2.00 
Stewart,  Pharmacy.  2d  Ed.  1.00 
Ward's  Chemistry.     2d  Ed.     i.oo 

DEFORMITIES. 

Churchill,     Face  and  Foot.  3.50 

Coles.    Of  Mouth.  -  4.50 

Prince.     Orthopaedics.     -  4.50 

Reeves.  "  -  2.25 

DENTISTRY. 

Barrett.     Dental  Surg.   -  i.oo 

Flagg.     Plastics.      -        -  4.00 

Gorgas.     Dental  Medicine.  3.25 

Harris.     Principles  and  Prac.  6.50 

Dictionary  of.       -  6.50 

Heath.  Dis.  of  Jaws.  -  4.50 
Leber    and    Rottenstein. 

Caries.    -        -        -        -  1.25 

Richardson.     Mech.  Dent.  4.50 

Stocken.     Materia  Medica.  2.50 

Taft.    Operative  Dentistry.  4.25 

,  Inde.x  of  Dental  Lit.  2.00 

Tomes.     Dental  Surgery.  5.00 

Dental  Anatomy.  

■White.    Mouth  and  Teeth.  .50 

DICTIONARIES. 
Cleveland's  Pocket  Medical.     .70 
Cooper's  Surgical.   -        -         12.00 
Harris'  Dental.        -        -  6.55 

Longley's  Pronouncing  -  i.oo 

DIRECTORY. 

Medical,  of  Philadelphia, 
Pa.,  Del.  and  South  N.  J.  2.50 
EAR. 
Burnett.  Hearing,  etc.  .50 
Jones.  Aural  Surgery.  -  2  75 
Pritchard.  Diseases  of.  1.50 
Randall  &  Morse.  Atlas.  500 
■Woakes.  Deafness,  etc.  1.50 
Catarrh,  etc.         -         

ELECTRICITY. 
Althaus.  Medical  Electricity. $6. 00 
Mason's  Compend.  -  i.oo 

Reynolds.    Clinical  Uses.         i.oo 

EYE. 
Arlt.     Diseases  of   -        -  2.50 

Carter,    Eyesight.  -        -  1.25 

Daguenet.  Ophthalmoscopy.  1.50 
Fox  and  Gould.  Compend.  i.oo 
Gowers.  Ophthalmoscopy.  6.00 
Harlan.     Eyesight.  -  .50 

Hartridge.     Refraction.  2.00 

Higgins.     Handbook.     -  .50 

Liebreich.    Alias  of  Ophth.    15.00 
Macnamara,     Diseases  of.       4.00 
Meyer  and    Fergus,      Com- 
plete Text-Book,  with  Colored 
Plates.     -        -        -        -         4.50 
Morton,     Refraction.  3d  Ed.    i.oo 


FEVERS. 

Collie,  On  Fevers.  -        -  2  50 

Welch.     Enteric  Fever.  2.00 

HEADACHES. 

Day.     Their  Treatment,  etc.  1.25 
Wright.     Causes  and  Cure.       .50 
HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.    Thebkin.        -  .50 

Burnett,     Hearing.  -  .50 

Cohen.  Throat  and  Voice.  .50 
Dulles.     Emergencies.    -  .75 

Harlan.     Eyesight.  -  .50 

Hartshorne.    Uur  Homes.        .50 

Hufeland.  Long  Life.  -  i.oo 
Lincoln,     Hygiene.         -  .50 

Osgood.     Winter.    -        -  .50 

Packard.    Sea  Air,  etc.  .50 

Richardson's  Long  Life.  .50 

Tanner.     On  Poisons.     -  .75 

White.  Mouth  and  Teeth.  .50 
■Wilson.     Summer.  -  .50 

■Wilson's  Domestic  Hygiene,  i.oo 
Wood      Brain  Work.      -  .50 

HEALTH   RESORTS. 

Madden.     Foreign.  -  2  50 

Packard.  Sea  Air  and  Bath'g.  .50 
Solly.     Colorado  Springs.  .25 

HEART. 

Balfour.     Diseases  of     -  5.00 

Fothergill.     Diseases  of.  3.50 

Sansom.     Diseases  of     -  1.25 

HISTOLOGY. 

(See  Micoscope  and  Pathology. 

HOSPITALS. 

Burdett.     Cottage  Hospitals.  4.50 

Pay  Hospitals.      -  2.25 

Domville.     Hospital  Nursing.    .75 

HYGIENE. 
Bible  Hygiene.       -        -  i.oo 

Frankland.  Water  Analysis,  i.oo 
Fox.     Water,  Air,  Food.  4.00 

Lincoln.  School  Hygiene.  .50 
Parke's  Hygiene.  7th  Ed.  Net.  4.00 
Wilson's  Handbook  of.  -  2.75 

Domestic.     -        -  i.oo 

Drainage.     -        -  i.co 

Naval.  -        -  3.00 

KIDNEY  DISEASES. 
Beale.     Renal  and  Urin.  1.75 

Edwards.     How  to  Live  with 

Bright's  Disease.    -        -  .50 

Greenhow.  Addison's  Dis.  3.00 
Ralfe.  Dis.  of  Kidney,  etc.  2.75 
Tyson.     Bright's  Disease.         3.50 

LIVER. 

Habershon.     Diseases  of.         1.50 

Harley.     Diseases  of.      -  3.00 

LUNGS  AND  CHEST. 

See  Phy.  Diagnosis  and  Throat. 

Williams.     Consumption.        5.00 

MARRIAGE. 
Ryan.     Philosophy  of     -  i.oo 

MATERIA  MEDICA. 
Biddle.     loth  Ed.    -        -  4.00 

Charteris.     Manual  of.  -         

Gorgas.  Dental.  2d  Ed.  3.00 
Merrell's  Digest.  -  4.00 

Phillips.     Vegetable.       -  7.50 

Potter's  Compend  of.  4lh  Ed.  i.co 

Handbook  of  -  3.00 

Roberts'  Compend  of.     -  2.C0 


CLASSIFIED  LIST  OF  P.  BLAKISTON,  SON  Q^  CO.'S  PUBLICA  TIONS. 


MEDICAL  JURISPRUDENCE. 
Abercrombie's  Handbook,  2.50 
Reese's  Text-book  of.  3.00;  Sh.  3.50 
Woodman  and  Tidy's  Treat- 
ise, including  Toxicology.  7.50 
MICROSCOPE. 
Beale.     How  to  Work  with.     7.50 

In  Medicine.         -  7.50 

Carpenter.     The  Microscope.  5.50 
Lee.     Vade  Mecum  of.    -  3.00 

MacDonald.     Examination  of 

Water  by.        ... 
Martin.     Mounting. 
Wythe.     The  Microscopist. 
MISCELLANEOUS. 
Allen.     The  Soft  Palate. 
Beale.     Life  Theories,  etc. 
Slight  Ailments. 

Our  Morality. 

Black.     Micro-Organisms. 
Cjbbold.     Parasites,  etc. 
Edwards.     Malaria. 

Vaccination. 

Gross.     Life  of  Hunter. 
Haddon.     Embryology.    - 


2.75 

$-2.  75 

3.00 

•50 
2.00 
1.25 
1. 00 
1.50 
5. CO 

■50 
•50 

1-25 

6.00 


.50 

•75 
1. 00 


Hare.    Tobacco.  Paper,  .50 

Henry.     Anaemia.   -        -  .75 

Hodge.  Foeticide.  -  Paper,  .30 
Holden.  The  Sphygmograph.  2.00 
Kane.     Opium  Habit.      -  1.25 

MacMunn.  The  Spectroscope  3.00 
Murrell.  Massage.  2d  Ed.  1.25 
Smythe.  Med'l  Heresies. 
Sutton.  Ligaments. 
Wickes.  Sepulture. 

NERVOUS  DISEASES. 
Buzzard.     Ner.  Affections. 
Flower.    Atlas  of  Nerves. 
Gowers.    Manual  of.  In  i  vol. 

■    Dis.  of  Spinal  Cord.      

•     Diseases  of  Brain.         

Epilepsy.      -        -  

Page.     Injuries  of  Spine.  3.50 

RadcliflFe.  Epilepsy,  Pain,  etc.  1.25 
Wilks.     Nervous  Diseases.      6.00 

NURSING. 

Brush,  Nursing  of  the  Insane.  

Culling\A?orth.     Manual  of.      i.oo 

Monthly   Nursing. 

Domville's  Manual. 
Hood.  Lectures  to  Nurses 
Liickes.  Hospital  Sisters.  i.oo 
Record  for  the  Sick  Room.  .25 
Temperature  Charts.    -  .50 

OBSTETRICS. 
Bar.    Antiseptic  Obstet.  1.75 

Barnes.  Obstetric  Operations.  3.75 
Cazeaux  and  Tarnier.     New 

Ed.     Colored  Plates.      -         11.00 
Galabin's  Manual  of.       -  3.00 

Glisan's  Text-book.  2d  Ed.  4.00 
Landis.     Compend.         -  i.oo 

Meadows.     Manual.       -  2.00 

Rigby  and  Meadow's.      -  .50 

Schultze.  Diagrams.  -  25.00 
Tyler  Smith's  Treatise.  4.00 

Swayne's  Aphorisms       -  1.25 

OSTEOLOGY. 

Holden's  Text-book.      -  

PATHOLOGY  &  HISTOLOGY. 
Aitken.    The  Ptomaines,  etc.    i.oo 

Bowlby.     Surgical  Path.  

Gibbes.    Practical.  -  1.75 

Gilliam.     Essentials  of.  -  2.00 

Paget's  Surgical  Path.     -  7.00 

Rindfleisch.     General.  2.00 

Sutton.     General  Path.  -  4.50 

Virchow.     Post-mortems.         i.oo 

Cell.  Pathology.  -  4.C0 

Wilkes  and  Moxon.    -  6.00 

PHARMACY. 
Beasley's  Druggists'  Rec'ts.    2.25 

i'ormulary.     -        -  2.25 

Fliickiger.  Cinchona  Barks.  1.51 
Kirby.  Pharm.  of  Remedies.  2.25 
Mackenzie.  Phar.  of  Throat.  1.25 


Merrell's  Digest.     -        -  4.00 

Piesse.     Perfumery.        -  5.50 

Proctor.  Practical  Pharm.  4.50 
Roberts.     Compend  of.  2.00 

Stewart's  Compend.  2d  Ed.  i.oo 
Tuson.     Veterinary  Pharm.     2.50 

PHYSICAL  DIAGNOSIS 
Bruen's  Handbook.     2d  Ed.     i  50 

PHYSIOLOGY. 
Beale's  Bioplasm.    -        -  2.25 

Brubaker's  Compend.     -  i.oo 

Kirkes'   nth   Ed.     (Author's 

Ed.)  Cloth,  4.00;  Sheep,  5.00 
Landois'  Text-book.  2d  Ed.  6.50 
Sanderson's  Laboratory  B'k.  5.00 
Tyson's  Cell  Doctrine.    -  2.00 

Yeo's   Manual.    2d  Ed.    CI.,  3.00; 
Sheep,  3.50 
POISONS. 
Aitken.    The  Ptomaines,  etc.    100 
Black.     Formation  of.     -  i  50 

Reese.    Toxicology.        -  4.00 

Tanner.     Memoranda  of.  .75 

PRACTICE. 
Aitken.     2  Vols.     New  Ed.     12.00 
Beale.     Slight  Ailments.  1.25 

Charteris.  Handbook  of.  1.25 
Fagge's  Practice.  2  Vols.  10.00 
Fenwick's  Outlines  of.    -  1.25 

Hughes.  Compend  of.  2  Pts.  2.00 
Roberts.  Text-book.  5th  Ed.  5.00 
Tanner's  Index  of  Diseases.  3.00 
Warner's  Case  Taking.  1.75 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2.25 

Receipt  Book.        -  2.25 

Formulary.     -        -  2.25 

Pereira's  Pocket-book.  i.oo 

Wythe's  Dose  and  Symptom 

Book.     17th  Ed.      Just  out.  I.oo 
RECTUM  AND  ANUS. 
Allingham.    Diseases  of.  1.25 

Cripps.    Diseases  of         -  4.50 

SKIN  AND  HAIR. 
Anderson's  Text-Book.  4.50 

Bulkley.  The  Skin.  -  %  .50 
Cobbold.     Parasites.        -  5.00 

Van   Harlingen.      Diagnosis 

and  Treatment  of  Skin  Dis.  i  75 
Wilson.     Skin  and  Hair.  i.oo 

STIMULANTS  &  NARCOTICS. 
Anstie.     On.    -        -        -  3.00 

Hare,  Tobacco.  Paper,  .50 

Kane.  Opium  Habit,  etc.  1.25 
Lizars.     On  Tobacco.     -  .50 

Miller.     On  Alcohol        -  .50 

Parrish,     Inebriety.         -  1.25 

SURGERY. 
Butlin.      Surg,    of    Malignant 

Diseases.  ...        

Gamgee.     Wounds  and  Frac- 
tures.      -        -        -         -  3.50 
Heath's  Operative.          -        12.00 

Minor.    8th  Ed.      -  2.00 

Surgical  Diagnosis.  1.25 

Diseases  of  Jaws.  4.50 

Horwitz.   Compend.    3d  Ed.    i.oo 
Porter's    Surgeon's    Pocket- 
book.       -         ■         -        - 

Pye.     Surgical  Handicraft. 
Roberts.     Surgical  Delusions 

(A.  S.)   Ckib-Foot. 

Smith.     Abdominal  Surg. 


2.25 
5.00 
■50 
•  50 
5.00 
1.50 
3  00 


Swain.     Surg.  Emergencies. 
Walsham.     Practical  Surg. 
Watson's  Amputations. 
TECHNOLOGICAL  BOOKS. 
Sec  also  Chemistry. 
Cameron.     Oils  &  Varnishes.  2.50 

Gardner.     Brewing,  etc.  1.75 

Gardner.     Acetic  Acid,  etc.  1.75 

Bleaching  S:  Dyeing.  1.75 

Overman.     Mineralogy.  i  00 

Piesse.     Perfumerj',  etc.  5.50 

Piggott.     On  Copper.     -  i.o^ 

Thompson.     Physics.     -  — — 


THERAPEUTICS. 
Biddle.     loth  Ed.    -        -  4.C0 

Cohen.     Inhalations.        -  1.25 

Field.  Cathartics  and  Emetics.  1.75 
Headland.  Action  of  Med.  3.0D 
Kirby.  Selected  Remedies.  2.25 
Mays.     Therap.  Forces.  1.25 

Ott.  Action  of  Medicines.  2.00 
Phillips.     Vegetable.       -  7.50 

Potter's  Compend.  -  i.oo 

Handbook  of.  3.00:811.3.50 

Waring's  Practical.        -  ^.00 

THROAT  AND  NOSE. 
Cohen.     Throat  and  Voice.        .50 

Inhalations.  -  1.25 

Greenhow.     Bronchitis.  1.25 

Holmes.     Laryngoscope.  i.oo 

James.     Sore  Throat       -  1.25 

Journal  of  Laryngology.  3.00 
Mackenzie.  Throat  and  Nose. 

New    Ed.     Complete   in  one 
vol.     New  lUus.,  etc.       -        

The  CEsophagus,  Naso- 
pharynx, etc. 

Larynx. 

Pharmacopoeia.    - 

Potter.     Stammering,  etc. 
Woakes.   Post-Nasal  Catarrh. 

Nasal  Polypus,  etc. 

Deafness,  Giddiness,  etc. 

TRANSACTIONS  AND 

REPORTS. 

Penna.  Hospital  Reports.      1.25 

Power  and  Holmes'  Reports.   1.25 

Trans.  College  of  Physicians.  3.50 

Amer.  Surg.  Assoc.        4.00 

TUMORS  AND  CANCER.     ' 
Hodge.     Note-book  for.  .50 

Thompson.  Of  the  Bladder.  1.75 
Wells.     Abdominal.         -  1.50 

URINE  &  URINARY  ORGANS. 
Acton.     Repro.  Organs.  2.00 

Beale.     Urin.  &  Renal  Dis.      1.75 

Urin.  Deposits.    Plates.  2.00 

Legg.     On  Urine.     -         -  .75 

Marshall  and  Smith.  Urine,  i.oo 
Ralfe.  Kidney  and  UrI.  Org.  2.75 
Thompson.  Urinary  Organs.  1.25 

Surg,  of  Urin.  Organs.    1.25 

Calculous  Dis.       -  i.oo 

Lithotomy.     -        -  3  50 

Prostate.     6th  Ed.  2.00 

Tyson.     Exam,  of  Urine.  1.50 

VENEREAL  DISEASES. 
Cooper.     Syphilis.  -        -  3.50 

Durkee.     GonorrhcEa.      -  3.50 

Hill  and  Cooper's  Manual,  i.oo 
Lewin.     Syphilis.  -        -  1.25 

VETERINARY  PRACTICE. 
Tuson's  V'et.  Pharmacopceia.  2.50 

VISITING   LISTS. 
Lindsay    and    Blakiston's 

Regular  Edition.  i.oo  to  3.C0 

Perpetual  Edition.  1.25 

WATER. 

Fox.     Water,  Air,  Food.  4.00 

Frankland.    Analysis  of.  i.oo 

MacDonald.        "        "  2.75 

WOMEN,  DISEASES  OF. 

Byford's  Text-book.  4th  Ed.  

Uterus.  -        -        -  1.25 

Courty.  .Uterus,  Ovaries,  etc.  7.50 
Dillnberger.  and  Children.  1.50 
Doran.  Gvnaec.  Operations.  4.50 
Duncan.     Sterility.  -  2.00 

Galabin.     Diseases  of.     -  3.00 

Savage.  Pelvic  Organs.  12.00 
Scanzoni.  Sexual  Organs  of.  4.03 
Tilt.     Change  of  Life.     -  1.25 

Winckel,  by  Parvin.    Manual 
of.  Illus.  Clo.,3.00;  Sh.  3.50 


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GALABIN'S  MIDWIFERY.  A  Manual  of  Midwifery.  By  Alfred  Lewis  Galabin, 
>:.A.,  M.D.,  Obstetric  Physician  and  Lecturer  on  Midwifery  and  the  Diseases  of  Women  at 
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GOODHART  AND  STARR,  DISEASES  OF  CHILDREN.  By  J.  F.  Goodhart, 
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taining, also,  an  Index  of  Diseases,  with  a  list  of  the  Medicines  applicable  as  Remedies,  and 
a  full  Index  of  the  Medicines  and  Preparations  noticed  in  the  work.  By  Edward  John 
Waring,  M.D. ,F.R.c. p.,  F.L.s,  etc.  4th  Edition.  Rewritten  and  Revised.  Edited  by  Dudley 
W.  Buxton,  m.d.,  Asst.  to  the  Prof,  of  Medicine  at  University  College  Hospital;  Member 
of  the  Royal  College  of  Phvsicians  of  London.     666  pages.     Cloth,  S3.00;  Leather,  33.50 

PARVIN'S-WINCKEL'S  DISEASES  OF  WOMEN.  A  Treatise  on  the  Diseases  of 
Women.  By  Dr.  V.  Win'CKEL,  Professor  of  Gynaecology  and  Director  of  the  Royal  Uni- 
versity Clinic  for  Women,  in  Munich.  Translated  from  the  German  by  Dr.  J.  H.  Wil- 
LiA.MsON,  Resident  Physician  Allegheny  General  Hospital,  .Vllegheny,  Penn'a,  under  the 
supervision  of,  and  with  an  Introduction  by,  Theophilus  Parvin,  m.d..  Professor  of  Ob- 
stetrics and  Diseases  of  Women  and  Children  in  Jefferson  Medical  College.  Illustrated  by 
117  fine  Engravings  on  Wood,  most  of  which  are  new.    674  pp.    Cloth, 33.00;  Leather,33.50 

YEO'S  MANUAL  OF  PHYSIOLOGY.  Second  Edition.  A  New  Textbook  for 
Students.  By  Gerald  F.  Veo,  m.d.,  f.r.c.s..  Professor  of  Physiology  in  King's  College, 
London.     Over  301  lllu.strations  and  a  Glossary.    743  pages.    Cloth,  33-00;  Leather,  $3.50 

WALSHAM'S  PRACTICAL  SURGERY.    A  Manual  for  Students  and  Physicians.    By 
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omew's  Hospital ;  Surgeon  to  Metropolitan  Free  Hospital,  London,  etc.      With  236  Illus- 
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ACTON.  The  Functions  and  Disorders  of  the  Reproductive  Organs  in  Child- 
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AITKEN.  Science  and  Practice  of  Medicine.  By  William  Aitken,  m.d.,  f.r.s., 
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Edition.  Revised  throughout.  196  Engravings  on  Wood,  and  a  Map.  2  vols. 
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Animal  Alkaloids,  the  Ptomaines,  Leucomaines  and  Extractives  in  their 
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ALLEN'S  New  Method  of  Recording  the  Motions  of  the  Soft  Palate.     By  Harrison 

Allen,  m.d..  Professor  of  Physiology  University  of  Pennsylvania.       Cloth,  .50 

ALLINGHAM.     Diseases  of  the  Rectum.     Fistula,  Haemorrhoids,  Painful  Ulcer, 

Stricture,  Prolapsus,  and  other  Diseases  of  the    Rectum,  their   Diagnosis  and 

Treatment.       By  William  Allingham,  f.r.c.s.      Fourth   Edition,    Enlarged. 

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ALTHATJS.  Medical  Electricity.  Theoretical  and  Practical.  Its  Use  in  the  Treat- 
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ANDERSON.  A  Treatise  on  Skin  Diseases.  With  special  reference  to  Diagnosis 
and  Treatment,  and  including  an  Analysis  of  ir.ooo  consecutive  cases.  By  T. 
McCall  Anderson,  m.d.,  Professor  of  Clinical  Medicine,  LTniversity  of  Georgia. 
With  several  Full  Page  Plates,  two  of  which  are  Colored  Lithographs,  and  nu- 
merous Wood  Engravings.     Octavo.     650  pages.       Cloth,  $4.50;  Leather,  S5. 50 

ANSTIE.  Stimulants  and  Narcotics.  With  special  researches  on  the  Action  of 
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ARLT.  Diseases  of  the  Eye.  Clinical  Studies  on  Diseases  of  the  Eye.  Including  the 
Conjunctiva,  Cornea  and  Sclerotic,  Iris  and  Ciliary  Body.  By  Dr.  Ferd.  Ritter 
VON  Arlt,  University  of  Vienna.  Authorized  Translation  by  Lyman  Ware, 
M.D.,  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  Chicago. 
Illustrated.     8vo.  Cloth.  52.50 

BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Methods  Applied  to 
Obstetric  Practice.  By  Dr.  Paul  Bar,  Obstetrician  to,  formerly  Interne  in,  the 
Maternity  Hospital,  Paris.  Authorized  Translation  by  Henry  D.  Fry,  m.d.. 
with  an  Appendix  by  the  author.     Octavo.  Cloth.  1.75 

BALFOUR.  Clinical  Lectures  on  Diseases  of  the  Heart  and  Aorta.  By  G.  W. 
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5 


6  P.  BLAKISTON,  SON  <S-  CO:S  

BARNES.  Lectures  on  Obstetric  Operations,  includingr  the  Treatment  of  Hemor- 
rhage, and  forming  a  Guide  to  Difficult  Labor.  By  Robert  Barnes,  m.d., 
F.R.c.P.     Fourth  Edition.     Illustrated.     8vo.  Cloth.  J3.75 

BAREETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
and  Dentistr)'.     Extraction  of  Teeth,  etc.     By  A.  W.  Barrett,  m.d.    Illustrated. 

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BARTLEY.     Medical  Chemistry.     A  Text-book  for  Medical  and  Pharmaceutical 
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Long  Island  College    Hospital;  President  of  the   American    Society  of  Public 
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BEALE.     On  Slight  Ailments ;  their  Nature  and  Treatment.     By  Lionel  S.  Beale, 
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Our  Morality,  and  the  Moral  Question,  from  the  Medical  Side.       Cloth,  $1.00 
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The  Use  of  the  Microscope  in  Practical  Medicine.    For  Students  and 
Practitioners,  with  full  directions  for  examining  the  various  secretions,  etc., 
in   the  Microscope.     Fourth  Edition.     500  Illustrations.     8vo.     Cloth,  $7.50 

How  to  Work  with  the  Microscope.     A  Complete  Manual  of  Microscopical 
Manipulation,    containing   a  full    description    of  many   new   processes    of 
investigation,   with    directions    for    examining   objects   under  the    highest 
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Bioplasm.     A  Contribution  to  the  Physiology  of  Life,  or  an  Introduction  to  the 
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from  the   Practice   of  the   most  Eminent  Physicians  and   Surgeons — English, 
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Pocket  Formulary  and  Synopsis  of  the  British  and  Foreign  Pharmacopceias. 
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Compounds  Employed  in  Medical  Practice.    Eleventh  Edition.    Cloth,  $2.25 
BENTLEY  AND  TRIMEN'S  Medicinal  Plants.    A  New  Illustrated  Work,  con- 
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included.     By  R.  Bentley,  f.r.s..  Professor  of  Botany,  King's  College,  London, 
and   H.  Tri.men,  m.b.,  f.h.s..  Department  of  Botany,  British    Museum.     Each 
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MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  7 

BIBLE  HYGIENE ;  or  Health  Hints.  By  a  physician.  Written  to  impart  in  a 
popular  and  condensed  form  the  elements  of  Hygiene ;  showing  how  varied  and 
important  are  the  Health  Hints  contained  in  the  Bible,  and  to  prove  that  the 
secondary  tendency  of  modern  Philosophy  runs  in  a  parallel  direction  with  the 
primary  light  of  the  Bible.     lamo.  Cloth,  $i.oo 

BIDDLE'S  Materia  Medica  and  Therapeutics.    Tenth  Edition.    For  the  Use  of 

Students  and  Physicians.  By  Prof.  John  B.  Biddle,  m.d.,  Professor  of  Materia 
Medica  in  Jefferson  Medical  College,  Philadelphia.  The  Tenth  Edition,  thor- 
oughly revised,  and  in  many  parts  rewritten,  by  his  son,  Clement  Biddle,  m.d.. 
Assistant  Surgeon,  U.  S.  Navy,  and  Henry  Morris,  m.d..  Demonstrator  of 
Obstetrics  in  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  of 
Philadelphia,  etc.  The  Botanical  portions  have  been  curtailed  or  left  out,  and 
the  other  sections,  on  Therapeutics  and  the  Physiological  action  of  Drugs,  greatly 
enlarged.  Cloth,  $4.00;  Leather,  $4.75 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons  by  Micro-Organisms.  A 
Biological  study  of  the  Germ  Theory  of  Disease.     By  G.  V.  Black,  m.d.,  d.d.s.' 

Cloth,  $1.50 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
Charles  L.  Bloxam,  Professor  of  Chemistry  in  King's  College,  London,  and  in 
the  Department  for  Artillery  Studies,  Woolwich.  Fifth  Edition.  With  nearly 
300  Engravings.     8vo.  Cloth,  $3.75  ;  Leather,  $4.75 

Laboratory  Teaching.  Progressive  Exercises  in  Practical  Chemistry.  In- 
tended for  use  in  the  Chemical  Laboratory,  by  those  who  are  commencing 
the  study  of  Practical  Chemistry.     4th  Edition.     89  lUus.  Cloth,  $1.75 

BOWLBY.  Surgical  Pathology.  By  Anthony  A.  Bowlby,  f.r.c.s.,  Surgical 
Register  and  Demonstrator  of  Surgical  Pathology  to  St.  Bartholomew's  Hospital, 
etc.  Nearly  Ready. 

BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  100  Illustrations. 
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Professor  of  Chemistry,  King's  College,  London.  Cloth,  $2.00 

BRATJNE.  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates, 
Photographed  on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other 
illustrations.  By  Wilhelm  Braune,  Professor  of  Anatomy  at  Leipzig.  Trans- 
lated and  Edited  by  Edward  Bellamy,  f.r.c.s.,  Lecturer  on  Anatomy,  Char- 
ing Cross  Hospital,  London.     4to.  Cloth,  $8.00;  Half  Morocco,  gio.oo 

BRITBAKER.  Physiology.  A  Compend  of  Physiology,  specially  adapted  for  the 
use  of  Students  and  Physicians.  By  A.  P.  Brubaker,  m.d..  Demonstrator  of 
Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
Dental  Surgery,  Philadelphia.  Third  Edition.  Revised,  Enlarged  and  Illus- 
trated. "No.  4,  ?Ouiz-Compend  Series?"  i2mo.  Cloth,  $1.00 
~                                 Interleaved  for  the  addition  of  notes,  $1.25 

BRUEN.  Physical  Diagnosis.  For  Physicians  and  Students.  By  Edward  T. 
Bruen,  m.d.,  Asst.  Professor  of  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania.    Illustrated  by  Original  Wood  Engravings.     i2mo.    2d  Ed.    Cloth,  $1.50 

BRUSH,  Manual  for  Attendants  on  the  Insane.  A  manual  for  the  Instruction  of 
Attendants  and  Nurses  in  Hospitals  for  the  Insane.  By  Edward  N,  Brush, 
m.d.,  Senior  assistant  Physician,  Department  of  Males,  Pennsylvania  Hospital  for 
Insane,  Philadelphia  ;  Late  Senior  Ass't.  Physician  N.  Y.  State  Lunatic  Asylum, 
Utica.  Including  lectures  on  Anatomy,  Chemistry,  Physiology,  Hygiene,  etc. 
i2mo.     Cloth. 

BTJCKNILL  AND  TUKE'S  Manual  of  Psychological  Medicine:  containing 
the  Lunacy  Laws,  the  Nosology,  /Etiology,  Statistics,  Description,  Diagnosis, 
Pathology  (including  morbid  Histology)  and  Treatment  of  Insanity.  By  John 
Charles  Bucknill,  m.d.,  f.r.s.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p. 
Fourth  Edition,  much  enlarged,  with  twelve  lithographic  and  numerous  other 
illustrations.     8vo.  Cloth,  $8.00 


p.  BLAKISTON,  SON  &-  CO.'S 


BULKLEY.    The  Skin  in  Health  and  Disease.    By  L.  Duncan  Bulkley,  m.d., 

Attending  Physician  at  the  New  York  Hospital.     Illustrated.  Cloth,  .50 

BITRDETT'S  Pay  Hospitals  and  Paying  Wards  throughout  the  World.     Facts  in 

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Cottage    Hospitals.     General,    Fever    and    Convalescent;    their   Progress, 

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BURNETT.    Hearing,  and  How  to  Keep  It.    By  Chas.  H.  Burnett,  m.d.,  Prof. 

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BUTLIN.    Operative  Surgery  of  Malignant  Diseases.    By  Henry  T.  Butlix, 

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BUZZARD.    Clinical  Lectures  on  Diseases  of  the  Nervous  System.    By  Thos. 

Buzzard,  m.d.     Illustrated.     Octavo.  Cloth,  $5.00 

BYFORD.     Diseases   of   Women.     The   Practice   of    Medicine   and    Surgery,    as 

applied  to  the  Diseases  of  Women.     By  W.  H.  Byford,  a.m.,  m.d.,  Professor  of 

Obstetrics  and  the  Diseases  of  Women  and  Children,  in  the  Chicago  Medical 

College.    Fourth  Edition.    Revised  and  Enlarged.    Over  300  Illustrations,  100  of 

which  have  been  drawn  and  engraved  specially  for  this  edition.     Nearly  Ready. 

On  the  Uterus.     Chronic  Inflammation  and  Displacement.  Cloth,  $1.25 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
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and  Lithographs.  Cloth,  $5.50 

CARTER.  Eyesight,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation 
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Illustrations,  Test  Types,  etc.     i2mo.  Paper,  .75;   Cloth,  $K25 

CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,"  by  Munde.  Eighth 
Revised  and  Enlarged  Edition.  With  Colored  Plates  and  numerous  other 
Illustrations.  The  Theory  and  Practice  of  Obstetrics  ;  including  the  Diseases 
of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc.  By  P.  Cazeaux, 
Member  of  the  Imperial  Academy  of  Medicine,  Adjunct  Professor  in  the  Faculty 
of  Medicine  in  Paris.  Remodeled  and  rearranged,  with  revisions  and  additions, 
by  S.  Tarnier,  m.d..  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Faculty  of  Medicine  of  Paris.  Eighth  American,  from  the 
Eighth  French  and  First  Italian  Edition.  Edited  and  Enlarged  by  Robert 
J.  Hess,  m.d.,  Physician  to  the  Northern  Dispensary,  Phila.,  etc.,  with  an  Ap- 
pendix by  Paul  F.  Munde,  m.d.,  Professor  of  Gynaecology  at  the  New  York 
Polyclinic,  and  at  Dartmouth  College  ;  Vice-President  American  Gynaecological 
Society,  etc.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and  other  Full- 
page  Plates,  seven  of  which  are  beautifully  colored,  and  numerous  Wood  En- 
gravings.    Two  Volumes,  Royal  Square  octavo.     1221  pages. 

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CHARTERIS.    The  Practice  of  Medicine.    A  Handbook.    By  M.  Charteris, 

m.d..  Member  of  Hospital  Staff  and  Professor  in  University  of  Glasgow.     With 

Microscopic  and  other  Illustrations.  Cloth,  $1.25 

Materia  Medica  and  Therapeutics.    A  Manual  for  Students.         In  Press. 

CHAVASSE.  The  Mental  Culture  and  Training  of  Children.  By  Pve  Henry 
CHA^'ASSE.     i2mo.  Cloth,  $1.00 

CHURCHILL.  Face  and  Foot  Deformities.  By  Fred.  Churchill,  m,d., 
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and  Two  Colored  Lithographs.     8yo.  Cloth,  $3.50 

CLEAVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
correct  Pronunciation  and  Definition  of  terms  used  in  medicine  and  the  col- 
lateral sciences,  abbreviations  used  in  prescriptions,  list  of  poisons,  their  anti- 
dotes, etc.  By  C.  H.  Cleaveland,  m.d.  Thirty-second  Edition.  Very  small 
pocket  size.  Cloth,  .75;  Tucks  with  Pocket,  $1.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

COBBOLD.  A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some 
account  of  the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  Illus- 
trations.    8vo.  Cloth,  $5.cxD 

COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
the  Apparatus  Employed,  etc.  By  J.  Solis  Cohen,  m.d.  With  cases  and  Illus- 
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The  Throat  and  Voice.    Illustrated.     i2mo.  Cloth,  .50 

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GOODHART  and  STARR'S  Diseases  of  Children.  The  Student's  Guide  to  the 
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Spinal  Cord.  Diagnosis  of  Diseases  of  the  Spinal  Cord.  With  Colored  Plates 
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HADDON'S  Embryology.  An  Introduction  to  the  Study  of  Embryology.  For 
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HANDY'S  Text-Book  of  Anatomy  and  Guide   to    Dissections.     For  the  Use  of 

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HARLAN.  Eyesight  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d.. 
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Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  of 
"  Dictionary  of  Medical  Terminology  and  Dental  Surgery."  Eleventh  Edition. 
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HARTRIDGE.  Refraction.  The  Refraction  of  the  Eye.  A  Manual  for  Students. 
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at  Jefferson  Medical  College,  Philadelphia.  In  two  parts.  Being  Nos.  sandj, 
?  Quiz-  Compend  ?  Series. 

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Paper  .75  ;  Cloth,  $1.25 


14  P.  BLAKISTON,  SON  &^  CO:S 

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Illustrated.  Second  Edition,  Revised  and  Enlarged,  with  new  Wood  Engravings. 
i2mo.  Cloth,  I2.75 

JOURNAL  of  Laryngology  and  Rhinology.  A  Monthly  Analytical  Record, 
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KIRBY.  Selected  Remedies.  A  Pharmacopoeia  of  Selected  Remedies,  with 
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KANE'S  Drugs  that  Enslave.  The  Opium,  Morphine,  Chloral,  and  Similar 
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of  Women,  in  Starling  Medical  College,  Columbus,  Ohio.  Third  Edition. 
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logical Institute  in  the  University  of  Greifswald.  Second  American,  translated 
from  the  Fifth  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.sc. 
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LEWIN  on  Syphilis.  The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  15 

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MACKENZIE  on  the  Throat  and  Nose.  Complete  in  one  octavo  vol.  Including 
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MoRELL  Mackenzie,  m.d.,  Senior  Physician  to  the  Hospital  for'  Diseases  of 
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Medical  College,  etc.  Revised  and  Edited  by  D.  Bryson  Delavax,  m.d..  Prof, 
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MADDEN.  Health  Resorts  for  the  Treatment  of  Chronic  Diseases.  The  result 
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16  P.  BLAKISTON,  SON  &>  CO:S 

MARSHALL.  Anatomical  Plates;  or  Physiological  Diagrams.  Life  Size  (4  by 
7  feet.)  Beautifully  Colored.  By  John  Marshall,  f.r.s.  New  Edition.  Re- 
vised and  Improved,  Illustrating  the  Whole  Human  Body. 

The  Set,  1 1  Maps,  in  Sheets,  ^50.00 

The  Set,   11    Maps,   on  Canvas,  with  Rollers,  and  Varnished,  80.00 

An  Explanatory  Key  to  the  Diagrams,  ■  -S^ 

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The  Viscera  in  Position— The  Structure  of  the  Lungs.  No.  4.  The  Organs  of  Circulation.  No.  5. 
The  Lymphatics  or  Absorbents.  No.  6.  The  Digestive  Organs.  No.  7.  The  Brain  and  Nerves. 
No.  8.  The  Organs  of  the  Senses  and  Organs  of  the  Voice,  Plate  i.  No.  9.  The  Organs  of  the  Senses, 
Plate  2.  No.  10.  The  Microscopic  Structure  of  the  Textures.  No.  11.  The  Microscopic  Structure 
of  the  Textures. 

MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d.,  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
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MEDICAL  Directory  of  Philadelphia,  Pennsylvania,  Delaware  and  Southern  half 
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Philadelphia,  etc.,  etc.,  and  William  Pepper,  m.d..  Professor  of  the  Principles 
and  Practice  of  Medicine  in  the  Medical  Department,  University  of  Pennsyl- 
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MERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
the  use  of  Physicians,  Pharmacists  and  Students.  By  Albert  Merrell,  m.d. 
Octavo.  Half  dark  Calf,  $4.00 

MEYER.  Ophthalmology.  A  Manual  of  Diseases  of  the  Eye.  By  Dr.  Edouard 
Meyer,  Prof,  a  L'ficole  de  la  Faculte  de  Medicine  de  Paris,  Chev.  of  the  Legion 
of  Honor,  etc.  Translated  from  the  Third  French  Edition,  with  the  assistance 
of  the  author,  by  A.  Freedland  Fergus,  m.b..  Assistant  Surgeon  Glasgow. 
Eye  Infirmary.  With  270  Illustrations,  and  two  Colored  Plates.  Prepared 
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of  Ophthalmoscopy."     8vo.  Cloth,  $4.50;  Leather,  $5.50 

MILLER  and  LIZAR'S  Alcohol  and  Tobacco.  Alcohol.  Its  Place  and  Power. 
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MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including  the  Outlines 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  17 

MURRELL.  Massage  as  a  Mode  of  Treatment.  By  Wm.  Murrell,  m.d., 
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PHYSICIAN'S  VISITING  LIST.  Published  Annually.  Thirty-seventh  Year  of  its 
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sizes  and  prices. 

Tucks,  pocket  and  pencil,  Gilt  Edges,  .         .         $1.00 

'■         "  .         .  1.25 

•'         "  .         .  1.50 

"  "  "         <•         <«  _         _  2.00 

f  Jan.  to  June  I  ..,         ..         ..  ^. 

t  July  to  Dec.  J  "         *  "^ 

1  Jan.  to  June  I  ...         „         „  00 

I  July  to  Dec.  j  .         .  o 

INTERLEAVED    EDITION. 

For  25  Patients  weekly,  interleaved,  tucks,  pocket,  etc.,      "         ••          .         .  1.25 

50         "             "                 "                 "            "         .         •  J-50 

,,             ,,          1       (Tan.  to  June)      ,,        ,,         ..         <<  ^  r^ 
5°                           2  vols.    IJ^iytoDec.j                                              •         • 

Perpetual  Edition,   without  Dates  and  with  Special    Memorandum  Pages. 

For  25  Patients,  interleaved,  tucks,  pocket  and  pencil,            .         .         .         .  $1-25 

50         "                 "                ....  1.50 

EXTRA  Pencils  will  be  sent,  postpaid,  for  25  cents  per  half  dozen. 

8^=-  This  List  combines  the  several  essential  qualities  of  strength,  compactness,  durability 
and  convenience.  A  special  circular,  descriptive  of  contents  and  improvements,  will  be  sent 
upon  application.. 


r  25  Patients 
50 

75 
100         " 

weekly. 

50 

"  2  vols. 

lOO          " 

"  2  vosl. 

18  P.  BLAKISTON,  SON  &-  CO.'S 


PEREIRA'S  Prescription  Book.  Containing  Lists  of  Terms,  Phrases,  Contrac- 
tions and  Abbreviations  used  in  Prescriptions,  Explanatory  Notes,  Grammatical 
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Materia  Medica  and  Therapeutics,  Westminster  Hospital,  London.  Second 
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PIESSE'S  Art  of  Perfumery,  or  the  Methods  of  Obtaining  the  Odors  of  Plants,  and 
Instruction  for  the  Manufacture  of  Perfumery,  Dentrifices,  Soap,  Scented  Pow- 
ders, Cosmetics,  etc.  By  G.  W.  Septimus  Piesse.  Fourth  Edition.  366  Illus- 
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RADCLIFFE  on  Epilepsy,  Pain,  Paralysis,  and  other  Disorders  of  the  Nervous 
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RALFE.  Diseases  of  the  Kidney  and  Urinary  Derangements.  By  C.  H.  Ralfe, 
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Membrane,  and  Descriptive  Text.  By  B.  Alex.  Randall,  a.m.,  m.d.,  and 
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ROBERTS.  Club-Foot.  Clinical  Lectures  on  Orthopaedic  Surger)',  Nos.  I  and  II. 
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ROBERTS.     Practice  of  Medicine.     The  Theory  and  Practice  of  Medicine.     By 

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The  Human  Brain.  The  Field  and  Limitation  of  the  Operative  Surgery  of 
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20  P.  BLAKISTON,  SON  &-  CO.'S 

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SANSOM'S  Diseases  of  the  Heart.    Valvular  Disease  of  the  Heart.    By  Arthur 

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SAVAGE.  Atlas  of  the  Female  Pelvic  Organs.  The  Surgery,  Surgical  Pathology 
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tnken  from  nature,  with  Commentaries,  Notes  and  Cases.  By  Henry  Savage, 
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ored Plates,  comprising  many  Figures  and  many  Wood  Cuts.     Quarto. 

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SCANZONI.  Sexual  Organs  of  Women.  A  Practical  Treatise  on  the  Diseases 
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and  Diseases  of  Females,  University  of  Wiirzburg,  etc.  Edited  by  A.  K.  Gard- 
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SCHULTZE'S  Obstetrical  Plates.  Obstetrical  Diagrams.  Life  Size.  By  Prof.  B. 
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SMITH'S  Wasting  Diseases  of  Infants  and  Children.    By  Eustace  Smith,  m.d., 

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Clinical  Studies  of  Diseases  in  Children.    Second  Edition,  Revised.    8vo. 

Just  Ready.  Cloth,  $2.50 

SMITH.     Abdominal  Surgery.     Being  a  Systematic  Description  of  all  the  Princi 
pal  Operations.     By  J.  Greig  Smith,  m.a.,  f.r.s.e.,  Surg,  to  British  Royal  In' 
firmary.  Fellow  Royal  Med.  Chir.  Soc,  etc.     With  45  Engravings.     8vo.     600 
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SMYTHE'S  Medical  Heresies.  Historically  Considered.  A  Series  of  Critical  Es- 
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Sketch  and  Review  of  Homoeopathy,  Past  and  Present.  By  Gonzalvo  C. 
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lege of  Physicians  and  Surgeons,  Indianapolis,  Indiana.     i2mo.         Cloth,  $1.25 

SMI  fH  (TYLER).  Lectures  on  Obstetrics.  Dehvered  at  St.  Mary's  Hospital. 
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Annotations.    By  A.  K.  Gardner,  a.m.,  m.d.  233  IUus.  3d  Ed.  Svo.  Cloth,  $4.00 

STAMMER.  Chemical  Problems,  with  Explanations  and  Answers.  By  Karl 
Sta.m.mer.  Translated  from  the  2d  German  Edition,  by  Prof.  W.  S.  Hoskinson, 
A.M.,  Wittenberg  College,  Springfield,  Ohio.     i2mo.  Cloth.  .75 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of  the  Digestive 
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cal Pharmacy,  Phila.  College  of  Pharmacy  ;  Demonstrator  and  Lect.  in  Pharma- 
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STOCKEN'S  Dental  Materia  Medica.  Dental  Materia  Medica  and  Therapeutics 
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MEDICAL  AND  SCIENTIFIC  PUBLICATIONS 21 

SUTTON'S  Volumetric  Analysis.  A  Systematic  Handbook  for  the  Quantitative 
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Gases.  By  Francis  Sutton,  f.c.s.  Fifth  Edition,  Revised  and  Enlarged, 
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SUTTON.  Patholog-y.  An  Introduction  to  General  Pathology,  founded  on  three 
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John  Bland  Sutton,  f.r.c.s.,  Lecturer  on  Pathology,  Royal  College  of  Sur- 
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SWAYNE'S  Obstetric  Aphorisms,  for  the  Use  of  Students  commencing  Midwifery 
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TAFT'S  Operative  Dentistry.     A  Practical  Treatise  on  Operative  Dentistry.     By 
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sity College.     Third  Edition.     With  87  Engravings.     8vo.  Cloth,  $3.50 
Urinary  Organs.  Diseases  of  the  Urinary  Organs.  7th  London  Ed.  Cloth,  $1.25 
On  the  Prostate.     Diseases  of  the  Prostate.     Their  Pathology  and  Treatment. 
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Tilt,  m.d.     Fourth  London  Edition.     8vo.  Paper  cover,  .75  ;  Cloth,  $1.25 

TOMES'  Dental  Anatomy.  A  Manual  of  Dental  Anatomy,  Human  and  Compara- 
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TOMES.  Dental  Surgery.  A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s. 
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22  P.  BLAKISTON,  SON  &-  CO:S 

TRANSACTIONS  American  Surgical  Association.  Volumes  I  and  II.  Illus- 
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8vo.  Price  of  Vol.  I,  Cloth,  $3.50  ;  Vol.  II,  Cloth,  $4.00  ;  Vol.  Ill,  Cloth,  $3.50 
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TRIMBLE.  Practical  and  Analytical  Chemistry.  Being  a  complete  course  in 
Chemical  Analysis.  By  Henry  Trimble,  ph.g.,  Professor  of  Analytical  Chem- 
istry in  the  Philadelphia  College  of  Pharmacy.  Second  Edition.  Enlarged. 
Illustrated.     8vo.  Cloth,  $1.50 

TURNBTJLL'S  Artificial  Anaesthesia.  The  Advantages  and  Accidents  of  Artifi- 
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Asphyxia;  Spasms  of  the  Glottis;  Syncope,  etc.  By  Laurence  Turnbull,  m.d., 
PH.  G.,  Aural  Surgeon  to  Jefferson  College  Hospital,  etc.  Second  Edition,  Re- 
vised and  Enlarged.  With  27  Illustrations  of  Various  Forms  of  Inhalers,  etc., 
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Medicine.     By  Richard  V.  TusoN,  F.c.s.     Third  Edition.     i2mo.     Cloth,  §2.50 

TYSON.  Bright's  Disease  and  Diabetes.  With  Especial  Reference  to  Pathology 
and  Therapeutics.  By  James  Tyson,  m.d.,  Professor  of  Pathology  and  Morbid 
Anatomy  in  the  University  of  Pennsylvania.  Including  a  Section  on  Retinitis  in 
Bright's  Disease.  By  Wm.  F.  Norris,  m.d.,  Clin.  Prof,  of  Ophthalmology,  in 
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Guide  to  the  Examination  of  Urine.     Fifth  Edition.     For  the  Use  of 

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Cell  Doctrine.  Its  History  and  Present  State.  With  a  Copious  Bibliography 
of  the  subject.  Illustrated  by  a  Colored  Plate  and  Wood  Cuts.  Second 
Edition.     Svo.  Cloth,  $2.00 

Rindfleisch's  Pathology.  Edited  by  Prof.  Tyson.  General  Pathology ;  a 
Handbook  for  Students  and  Physicians.  By  Prof.  Edward  Rindfleisch, 
of  Wurzburg.  Translated  by  Wm.  H.  Mercur,  m.d.  Edited  and  Revised 
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DIAGRAM    OF   AXILLA 
(From.  Holden's  Anatotny.) 


Axillary  Artbrt. 
Brachial  Artery. 
Thoracica  HuMERARiA  Artery. 
Superior  Thoracic  Artery. 
Subscapular  Artery. 

DoRSALIS  SCAPUL.«  ArTERY. 

Posterior  Circumflex  Artery, 
Superior  Profunda  Artery. 
Posterior  Thoracic  Nerve. 
Long  Subscapular   Nerve. 
Median  Nerve. 
Cephalic  Vein. 
Musculo-cutaneous  Nbrvs. 
Teres  Major. 


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BY  E.  H.  HARTLEY,  M.D., 

Associate  Professor  of  Chemi';try  at  the  Long  Island  College  Hospital ;  President  of  the  American  Society  of 
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long  descriptions  of  substances  and  theories  of  interest  only  to  the  advanced  chemi- 
cal student. 

PART  I — Treats  of  Light,  Heat  and  Electricity,  which  are  described  at  some  length,  and  explanations  made 
and  applied  to  common  phenomena.  In  the  subject  of  light,  only  so  much  is  given  as  will  explain  the  theory 
and  use  of  the  spectroscope.  In  electricity,  the  principal  aim  has  been  to  give  such  information  as  is  needed 
for  the  proper  understandm^,  working  and  care  of  the  medical  battery. 

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as  are  necessary  to  an  understanding  of  the  subject  are  given  It  has  been  deemed  best  to  present  all  these 
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successful  in  an  experience  of  over  twelve  years  of  teaching. 

PART_  III — Treats  of  the  natural  history  of  the  elements,  of  their  principal  compounds,  with  their  physiological 
action  and  toxicology. 

PART  IV — Organic  bodies  commonly  tised  in  medicine  and  pharmacy.  The  principal  organic  substances 
derived  from  animal  life  are  given  a  place.  In  the  appendix  will  be  found  analyses  of  the  principal  secretions 
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Applied  Medical   Chemistry. 

Containing  a  description  of  the  apparatus  and  methods  employed  in  the  practice 
of  Medical  Chemistry,  the  Chemistry  of  Poisons,  Physiological  and  Pathological 
Analysis,  Urinary  and  Fecal  Analysis,  Sanitary  Chemistry  and  the  Examination  of 
Medicinal  Agents,  Foods,  etc. 

BY  LAWRENCE  WOLFF,  M.D., 

Demonstrator  of  Chemistry  in  the  Jefferson  Medical  College ;  Member  of  the  Philadelphia  College  of  Pharmacy 
and  of  the  Chemical  Section  of  the  Franklin  Institute,  etc. 

Octavo,  Cloth,  $1  50. 
%*The  object  oi  the  author  of  this  book  is  to  furnish  the  practitioner  and  student 
a  reliable  and  simple  guide  for  making  analyses  and  examinations  of  the  various 
medicinal  agents,  human  excretions,  secretions,  etc.,  without  elaborate  apparatus  or 
expensive  processes. 

Practical  and  Analytical  Chemistry. 

Being  a  complete  course  in  Chemical  Analysis,  for  pharmaceutical  and  medical 
students. 

BY  HENRY  TRIMBLE,  Ph.G., 

Professor  of  Analytical  Chemistry  in  the  Philadelphia  College  of  Pharmacy. 

Second  Edition.    Illustrated.    8vo.    Cloth,  $1.50. 

SUMMARY  OF  CONTENTS.  Part  I.  Practical— Preparation  and  Properties  of  Gases,  Preparation  of  Salts, 
etc.  Part  II.  Section  I — Bases.  Group  I — Potassium,  Sodium,  Lithium,  Ammonium.  Group  II — Barium, 
Strontium,  Calcium,  Magnesium.  Group  III — Manganese,  Zinc,  Cobalt,  Nickel.  Group  IV — Iron,  Cerium, 
Chromium,  Aluminium.  Group  V — Arsenic,  Antimony,  Tin,  Gold,  Platinum.  Group  VI — Mercury  (ic). 
Bismuth,  Copper,  Cadmium.  Group  VII -Silver,  Mercury  (ous).  Lead.  Section  II — Acids.  Section  III — 
Detection  of  Bases  and  Acids.  Section  IV — Some  of  the  Reactions  and  Tests  of  Purity  of  the  more  import- 
ant Organic  Compounds.  Part  III.  Quantitative  Chemical  Analysis.  Section  I — Gravimetric  Estimation. 
Section  II — Volumetric  Estimation.     There  are  also  a  number  of  useful  Tables. 

LEFPMANN'S  ORGANIC  AND  MEDICAL  CHEMISTRY.  Including 
Urine  Analysis  and  the  Analysis  of  Water  and  Food.  By  Henry  I.effmann, 
M.D.,  Demonstrator  of  Chemistry  at  Jefferson  Medical  College,  Philadelphia. 
l2mo.  Cloth,  $  I. go;  Interleaved  for  the  addition  of  Notes,  51.25 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


Practical  Handbooks 

FOR  THE  PHYSICIAN  and  MEDICAL  STUDENT. 


VAN  HARLINGEN  ON  SKIN  DISEASES.  A  Handbook  of  the  Diag- 
nosis and  Treatment  of  Skin  Diseases.  By  Arthur  Van  Harlingen,  m.d., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Polyclinic ;  Consulting 
Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases,  and  Dermatologist 
to  the  Howard  Hospital.  With  colored  plates  representing  the  appearance  of 
various  lesions.     i2mo.  Cloth,  $1.75 

*^4.*  This  is  a  complete  epitome  of  skin  diseases,  arranged  in  alphabetical  order, 
giving  the  diagnosis  and  treatment  in  a  concise,  practical  way.  Many  prescriptions 
are  given  that  have  never  been  published  in  any  text-book,  and  an  article  incorporated 
on  Diet.  The  plates  do  not  represent  one  or  two  cases,' but  are  composed  of  a  num- 
ber of  figures,  accurately  colored,  showing  the  appearance  of  various  lesions,  and 
will  be  found  to  give  great  aid  in  diagnosing. 

■"  This  new  handbook  is  essentially  a  small  encyclopsedia.  «  *  *  Contains  a  very  complete  summary  of  the 
present  state  of  Dermatology.  »  *  *  We  heartily  commend  it  for  its  brevity,  clearness  and  evidently  careful 
preparation." — Pkiladelpkia  Medical  Times. 

"The  author  shows  a  proper  appreciation  of  the  wants  of  the  general  practitioner." — Ne7u  York  Medical 
Record. 

"  It  is  concisely  and  intelligently  written,  and  contains  many  of  the  best  formulas  in  use  for  the  various  forms 
of  Skin  Disease." — JVe^u  York  Medical  Titties. 

"  This  is  an  excellent  little  book,  in  which,  for  ease  of  reference,  the  more  common  diseases  of  the  skin  are 
arranged  in  alphabetical  order,  while  many  good  prescriptions  are  given,  together  with  clear  and  sensible  direc- 
tions as  to  their  proper  application."— ^yi/o«  Medical  and  Surgical  yournal. 

''  It  is  just  the  kind  of  book  that  the  general  practitioner  will  find  most  convenient  for  reference,  and  we  feel 
confident  that  it  will  be  appreciated." — Southern  Practitioner. 

RINDFLBISCH'S  PATHOLOaY.  The  Elements  of  Pathology.  By  Prof. 
Edward  Rindfleisch,  University  of  Wiirzburg.  Authorized  translation  from 
the  first  German  edition,  by  Wm.  H.  Mercur,  m.d.  (Univ.  of  Pa.)  Revised  by 
James  Tyson,  m.d  ,  Professor  of  Pathology  and  Morbid  Anatomy  in  the  Univer- 
sity of  Pennsylvania.     i2mo.  Cloth,  $2.00 

Prof.  Tyson,  in  his  Preface  to  the  American  edition,  says  : — "A  high  appreciation  of  Prof.  Rindfleisch's 
work  on  Pathological  Histology,  caused  me  to  make  careful  examination  of  these  '  Elements'  immediately  after 
their  publication  in  the  original.  From  such  an  examination  I  became  satisfied  that  the  book  would  fill  a  niche 
in  the  wants  of  the  student,  as  well  as  of  others  who  may  desire  t3  familiarize  themselves  with  general  patho- 
logical processes,  viewed  from  the  most  modem  standpoint." 

BRUEN'S  PHYSICAL  DIAGNOSIS.  Second  Edition.  A  Pocket-book 
of  Physical  Diagnosis  of  the  Heart  and  Lungs ;  for  the  Student  and  Physician. 
By  Edward  T.  Bruen,  Demonstrator  of  Clinical  Medicine  in  the  University  of 
Pennsylvania;  Lecturer  on  Pathology  in  the  Women's  Medical  College  of  Phila- 
delphia ;  2d  Edition,  revised,  with  new  original  illustrations.     i2mo.    Cloth,  $1.50 

"  We  consider  the  description  of  the  manner  and  rules  governing  the  art  of  percussion  well  given.  The  sub- 
ject is  always  a  difficult  one  for  beginners,  and  requires  to  be  well  handled  in  order  to  be  properly  understood." 
• — American  yournal  of  Medical  Sciences. 

WOAKES  ON  CATARRH  AND  DISEASES  OF  THE  NOSE  CAUS- 
ING DEAFNESS.  By  Edward  Woakes,  m.d..  Senior  Aural  Surgeon  tj 
the  London  Hospital  for  Diseases  of  the  Throat  and  Chest.  29  Illustrations. 
i2mo.  Cloth,  $1.50 

"  Out  of  the  large  number  of  special  works  on  catarrh,  there  is  none  for  which  we  have  such  an  unqualified 
good  opinion.  •  »  «  The  subject  is  clearly  presented.  •  •  •  The  line  of  treatment  suggested  is  rational." 
— North  Carolina  Medical  yournal. 

P.  BLAKISTON,  SON  &  CO.,  1012  'Walnut  St.,  Philadelphia. 


THE  PRACTICAL  SERIES. 

TWO  NEW  VOLUMES  JUST  READY. 

*4{.*  The  volumes  of  this  series,  written  by  well-known  physicians  and  surgeons  of 
large  private  and  hospital  experience,  recognized  authorities  on  the  subjects  of  which 
they  treat,  will  embrace  the  various  branches  of  medicine  and  surgery.  They  are  of 
a  thoroughly  practical  character,  calculated  to  meet  the  requirements  of  the  practi- 
tioner, and  will  present  the  most  recent  methods  and  information  in  a  compact  shape 
and  at  a  low  price. 

Bound  Uniformly,  in  a  Handsome  and  Distinctive  Cloth  Binding. 
TREATMENT  OP  DISEASE  IN  CHILDREN.  Including  the  Outlines 
of  Diagnosis  and  the  Chief  Pathological  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.  d.,  m.r.c.p..  Assistant  Physician  to  the  Hospital 
for  Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital, 
London.     i2mo.     560  pages.  Cloth,  J3.00 

ON  FEVERS.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology,  Diag- 
nosis, Prognosis  and  Treatment.  By  Alexander  Collie,  m.d.,  m.r.c.p.,  Lond. 
Medical  Officer  Homerton  Fever  Hospital,  and  of  the  London  Fever  Hospital. 
With  Colored  Plates.  Cloth,  $2.50 

"  This  volume,  which  forms  one  of  the  '  Practical  Series'  of  Medical  and  Surgical  Manuals,  deserves  attention 
from  the  fact  that  its  author  has  been  so  long  devoted  to  the  subjects  of  which  it  treats.  He  is,  therefore,  in 
position  to  speak  with  authority  as  well  as  with  complete  freedom  and  in'^ependence.  *  *  *  *  '1  he  strongest 
parts  of  the  work  are  those  which  deal  with  diagnosis  and  treatment,  for  here  Dr.  Collie  is  thoroughly  at  home, 
and  succeeds  in  imparting  to  the  work  its  '  practical  character,  for  which  it  will  be  highly  valued.' " — London 
Lancet,  April  2jd,  1887. 

HANDBOOK  OP  DISEASES  OP  THE  EAR.  By  Urb.^n  Pritchard, 
M.D.,  F.R.C.S.,  Professor  of  Aural  Surgery,  King's  College,  London,  Aural  Sur- 
geon to  King's  College  Hospital,  Senior  Surgeon  to  the  Royal  Ear  Hospital,  etc. 
i2mo.  Cloth,  $1.50 

"  Exactly  what  is  wanted  at  the  present  moment,  we  can  recommend  every  practitioner  to  have  a  copy."— 
London  Practitioner. 

"A  first-rate  little  book.  *  *  *  The  man  who  wants  a  short,  reliable  book  will  buy  Dr.  Pritchard's. "— 
■  New  Orleans  Medical  and  Surgical  Journal. 

"Written  from  an  eminently  practical  standpoint.  *  *  *  *  Commended  for  its  simplicity  and  directness." 
— New  York  Medical  Journal. 

"  Belongs  to  a  class  that  is  very  useful  to  the  general  practitioner," — Maryland  Medical  Journal. 

DISEASES  OP  THE  KIDNEYS,  AND  URINARY  DERANGE- 
MENTS. By  C.  H.  Ralfe,  m.a.,  m.d.,  f.r.c.p.,  Assistant  Physician  to  the 
London  Hospital ;  late  Senior  Physician  to  the  Seamen's  Hospital,  Greenwich. 
i2mo.     With  Illustrations.     572  pages.  Cloth,  $2.75 

"It  is  with  keen  pleasure  that  we  recommend  this  really  meritorious  book  to  our  readers." — New  York  Medical 
Journal. 

"A  clear,  concise  and  systematic  account  of  urinary  pathology  and  therapeutics.  *  *  *  *  The  student 
will  find  in  these  pages  all  necessary  instruction  imparted  in  a  candid  and  not  dogmatic  manner,  and  the  practi- 
tioner will  find  a  ready  and  convenient  reference  book." — Boston  Medical  and  Surgical  yournal. 

BODILY  DEFORMITIES  AND  THEIR  TREATMENT.  A  Handbook 
of  Practical  Orthopaedics.  By  H.  A.  Reeves,  f.r.c.s..  Senior  Assistant  Surgeon 
and  Teacher  of  Practical  Surgery  at  the  London  Hospital ;  Surgeon  to  the  Royal 
Orthopsedic  Hospital,  etc.     i2mo.     228  Illustrations.     460  pages.        Cloth,  $2.25 

"  From  what  we  have  already  said,  it  will  be  seen  that  Mr.  Reeves  has  given  us  a  trustworthy  guide  for  the 
treatment  of  a  very  extended  class  of  cases  »  *  *  *  If  the  other  volumes  of  the  Practical  Series  are  as  gocd 
as  this,  we  shall  be  agreeably  disappointed." — American  Journal  of  Medical  Sciences,  April,  jjtSs- 

"  The  utility  of  the  work  now  before  us  cannot  be  better  recommended  to  the  appreciation  of  the  professional 
reading  public  than  by  recalling  that  it  is  the  first  of  its  kind,  dealing  with  orthopaedics  from  a  modern  stand- 
point.''—Hospital  Gazette  and  Students'  Journal. 

DENTAL  SURGERY  POR  GENERAL  PRACTITIONERS  AND 
STUDENTS  IN  MEDICINE.  By  Ashley  W.  Barrett,  m.d.,  m.r.c.s., 
Eng.,  Surgeon-Dentist  to,  and  Lecturer  on  Dental  Surgery  and  Pathology  in  the 
Medical  School  of,  London  Hospital.     i2mo.     Illustrated.  Cloth,  $1.00 

"Replete  with  an  abundance  of  practical  information  of  unquestionable  utility." — Hospital  Gazette  and 
Students'  Journal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


PERIODICALS  PUBLISHED  BY  P.  BLAKISTON,  SON  &  CO. 

THE   POLYCLINIC.     Vol.  V. 

A  Monthly  Journal  of  Medicine  and  Surgery.  Doubled  in  Size  Without  Increase  of  Price. 

$i.oo  PER  ANNUM.      SAMPLE  COPIES  FREE. 

EDITORIAL    STAFF. 
EDITOR-IN-CHIEF,  HENRY  LEFFMANN,  M.D. 

Diseases  of  the  Throat  and  Chest.  J.  Solis-Cohen,  m.d.,  Professor  of  Dis- 
eases of  the  Throat  and  Chest  in  the  Philadelphia  Polyclinic. 

General  Surgery,  Orthopaedics,  Operative  and  Clinical  Surg-ery.  John 
B.  Roberts,  m.d..  Surg,  to  St.  Mary's  Hosp. ;  Chas.  B.  Nanxrede.  m.d.,  Surg, 
to  the  Episcopal  and  to  St.  Christopher's  Hosps. ;  Lewis  W.  Steinbach,  .m.d., 
Wm.  Barton  Hopkins,  m.d.,  Asst.  Demonstrator  of  Surgery,   Univ.  of  Penna., 

A.  B.  HiRSH,  M.D. 

Diseases  of  the  Ear.  Charles  H.  Burnett,  m.d..  Aural  Surgeon  to  the  Presby- 
terian Hospital. 

Diseases  of  the  Mind  and  Nervous  System.  Charles  K.  Mills,  m.d.,  Lec- 
turer on  Mental  Diseases,  University  of  Pennsylvania  ;  Consulting  Physician 
Insane  Department,  Philadelphia  Hospital. 

Diseases  of  the  Skin.  Arthur  Van  Harlingen,  m.d.,  Consulting  Physician 
Dispensary  for  Skin  Diseases  ;  Physician  to  Howard  Hosp.  Dermatological  Dept. 

Diseases  of  the  Eye.  George  C.'Harland,  m.d.,  Surgeon  to  Wills  Eye  Hospi- 
tal and  to  the  Eye  and  Ear  Dept.,  Penna.  Hosp.;  Howard  F.  Ha^nsell,  m.d., 
Phvsician  to  Southeastern  Hospital  and  Manayunk  Eye  and  Ear  Dispensary. 

Genito -Urinary  and  Venereal  Diseases.  J.  Henry  C.  Simes,  m.d..  Surgeon 
to  Episcopal  Hospital. 

Clinical  Medicine.    Frederick  P.  Henry,  m.d..  Physician  to  Episcopal  Hospital. 

Gynaecology  and  Obstetrics.  Benj.  F.  Baer,  m.d.,  late  Instructor  in  Gynaecol- 
ogy, University  of  Pennsylvania;  Obstetrician  to  Maternity  Hospital. 

Diseases  of  "Women  and  Children.  Washington  H.  Baker,  m.d.,  Obstet- 
rician to  Maternity  Hospital. 

A  SPECIAL    OPFER.  To  each  new  subscriber,  who  remits  one  dollar,  in 

'  advance,  we  will  send  The  Polyclinic  for  one 
year  and  a  copy  of  the  following  book  :  Urinary  and  Renal  Derangements 
and  Calculous  Disorders,  with  Hints  on  Diagnosis  and  Treatment.  By 
Lionel  S.  Beale,  m.d.,  f.r.s.,  f.r.c.p..  Professor  of  the  Principles  and  Practice  of 
Medicine  in  King's  College,  London  ;  Physician  to  King's  College  Hospital.  i2mo. 
356  pages.     1885.     Bound  in  strong  paper  covers. 

The  Journal  of  Laryngology  and   Rhinology. 

An  Analytical  Record  of  Current  Literature  Relating  to  the  Throat  and  Nose.    Edited  by  MORELL 
MACKENZIE,  M.D.,  Lond.,  and  R.  NORRIS  WOLFENDEN,  M.D.,  Cantab. 

"With  the  Co-operation  of  Dr.  Fau\'el  (Paris),  Dr.  Joal  (Paris),  Prof.  Massei 
(Naples),  Prof.  Guye  (Amsterdam),  Dr.  Capart  (Brussels),  Dr.  Hunter  Mackenzie 
(Edinburgh),  Dr.  Michael  (Hamburg),  Dr.  Ramon  de  la  Sota  y  Lastra  (Seville), 
Dr.  John  N.  Mackenzie  (Baltimore),  Dr.  Holger  Mvgind  (Copenhagen),  Dr. 
S.MYLY  (Dublin),   and  Dr.  Greville  Macdonald  (London). 

PUBLISHED    MONTHLY.     PER  ANNUM,  $3.00.  SAMPLE  NUMBERS,  25c. 

"the    OPHTHALMIC    REVI E W. 

A  Monthly  Record  of  Ophthalmic  Science. 

Edited  by  JAMES  ANDERSON,  M.D. ,  London  ;  KARL  GROSSM  ANN,  Liverpool;  PRIESTLEY 
SMITH,  Birmingham,  and  JOHN  B.  STORY,  M.D.,  Dublin. 

MONTHLY.      SUBSCRIPTION   PER  ANNUM,  $3.00. 

The  Ophthalmic  Review  is  the  only  Journal  devoted  to  this  special  branch  of 
medicine  that  is  published  in  Great  Britain,  and  therefore  represents  the  advances 
made  in  that  country  as  no  other  periodical  can.     Sample  numbers,  25  cents. 


?  OUIZ-COMPENDS  ? 

A  NEW  SEEIES  OF  PRACTICAL  MANUALS  FOR  THE    PHYSICIAN  AND   STUDENT. 

Compiled  in  accordance  with  the  latest  teachings  of  prominent  lecturers 
and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical  and  exhaustive  set  of  manuals,  containing  information 
nowhere  else  collected  in  such  a  condensed,  practical  shape.  Thoroughly  up  to  the  times  in 
every  respect,  containing  many  new  prescriptions  and  formulae,  and  over  two  hundred  and  thirty 
illustrations,  many  of  which  have  been  drawn  and  engraved  specially  for  this  series.  The 
authors  have  had  large  experience  as  quiz-masters  and  attaches  of  colleges,  with  exceptional 
opportunities  for  noting  the  most  recent  advances  and  methods.  The  arrangement  of  the  sub- 
jects, illustrations,  types,  etc.,  are  all  of  the  most  approved  form,  and  the  size  of  the  books  is 
such  that  they  may  be  easily  carried  in  the  pocket.  They  are  constantly  being  revised,  so  as  to 
include  the  latest  and  best  teachings,  and  can  be  used  by  students  of  any  college  of  medicine, 
dentistry  or  pharmacy. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

No.  I.  Human  Anatomy.  Fourth  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  Over  100  Illustrations.  By  Samuel  O.  L.  Potter,  m.a.,  m.d  , 
late  A.  A.  Surgeon  U.  S.  Army.    Professor  of  Practice,  Cooper  Med.  College,  San  Francisco. 

Nos.  2  and  3.  Practice  of  Medicine.  Second  Edition.  By  Daniel  E.  Hughes,  m.d.. 
Demonstrator  of  Clinical  Medicine  in  Jefferson  Med.  College,  Phila.     In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (including  Physical  Diagnosis),  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

***  These  Httle  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms.  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  including 
a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embryology.  Third  Edition.  By  Albert  P.  Brubaker, 
M.D.,  Prof,  of  Physiology,  Penn'a  College  of  Dental  Surgery  ;  Demonstrator  of  Physiology 
in  Jefferson  Med.  College,  Phila.     Revised,  Enlarged  and  Illustrated. 

No.  5.  Obstetrics.  Illustrated.  Third  Edition.  For  Physicians  and  Students,  By 
Henry  G.  Landis,  m.d..  Prof,  of  Obstetrics  and  Diseases  of  Women,  in  Starling  Medical 
College,  Columbus.     Revised  Edition.     New  Illustrations. 

No.  6.  Materia  Medica,  Therapeutics  and  Prescription  Writing.  Fourth  Revised 
Edition.  With  especial  Reference  to  the  Physiological  Action  of  Drugs,  and  a  complete 
article  on  Prescription  Writing.  Based  on  the  Last  Revision  (Sixth)  of  the  U.  S.  Pharma- 
copoeia, and  including  many  unofficinal  remedies.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
late  A.  A.  Surg.  U.  S.  Army;  Prof,  of  Practice,  Cooper  Med.  College,  San  Francisco.  4th 
Edition,  with  Index. 

No.  7.  Inorganic  Chemistry.  New  Edition.  By  G.  Mason  Ward,  m.d..  Demonstrator 
of  Chemistry  in  Jefferson  Med.  College,  Phila.  Including  Table  of  Elements  and  various 
Analytical  Tables.     New  Edition. 

No.  8.  Diseases  of  the  Eye  and  Refraction,  including  Treatment  and  Surgery.  By  L. 
Webster  Fox,  m.d..  Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Medical 
College,  etc.,  and  Geo.  M.  Gould,  a.b.     40  Illustrations.  C 

No.  9.  Surgery.  Illustrated.  Third  Edition.  Including  Fractures,  Wounds,  Disloca- 
tions.  Sprains,  Amputations  and  other  operations;  Inflammation,  Suppuration,  Ulcers, 
Syphilis,  Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  M.d.,  Demonstrator  of  Anatomy, 
Jefferson  Medical  College.  Third  Edition.  Revised  and  Enlarged.  77  Formula;  and  91 
Illustrations. 

No.  10.  Organic  Chemistry.  Including  Medical  Chemistry,  Urine  Analysis,  and  the  Analy- 
sis of  Water  and  Food,  etc.  By  Henry  Leffmann,  m.d..  Demonstrator  of  Chemistry  in 
Jefferson  Med.  College;  Prof,  of  Chemistry  in  Penn'a  College  of  Dental  Surgery,  Phila. 

No.  II.  Pharmacy.  Based  upon  "Remington's  Text  Book  of  Pharmacy."  By  F.  E. 
Stewart,  m.d.,  ph.g.,  Quiz-Master  at  Philadelphia  College  of  Pharmacy.     Second  Ed. 

Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

J8@°"  These  books  are  constantly  revised  to  keep  up  with  the  latest  teachings  and  discoveries. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  Street,  Philadelphia. 


NOW  READY. 


With  Many  Improvements  for  1888. 

37th  YEAR. 
The  Physician's  Visiting  List. 


(LINDSAY  &  BLAKISTON'S.) 

CONTENTS. 

PosoLOGiCAL  Table,  Meadows. 

Disinfectants  and  Disinfecting. 

Examination  OF  Urine,  Dr.  J.  Daland, /'fl/rt/ »</<'« 
Poisons  and  Antidotes.  i        y^  .^^„v  "  Practical  Examination  of  Urine."      s>h 

Tub    Metric    or    French    Decimal    System    of  rjt.r'.^ 


Almanac  for  1888  and  1889. 

Table  of  Signs  to  be  used  in  keeping  a:i;ounts. 

Marshall  Hall's  Ready  Method  in  Asphyxia, 


Weights  and  Measures. 

DosB  Table,  revised  and  rewritten  for  1888,  by  Ho- 
bart  Amory  Hare,  m.  d.,  Demonstrator  of  Thera- 
peutics, University  of  Pennsylvania. 

List  of  New  Remediks  for  1888,  by  same  author. 

Aids  to  Diagnosis  and  Treatment  ok  Diseases  op 
THE  Eye,  Dr.  L.  Webster  Fox,  Clinical  Asst.  Eye 
Dept.  Jefferson  Medical  College  Hospital,  and  G. 
M.  Gould. 

Diagram  Showing  Eruption  of  Milk  Teeth,  Dr. 
Louis  Starr,  Prof,  of  Diseases  of  Children,  Univer' 


Edition. 

Incompatibility,  Prof.  S.  O.  L.  Potter. 

A  New  Complete  Table  for  Calculating  the 
Period  of  Utero-Gestation, 

Sylvester's  Method  for  Aktificial  Respiration. 

Diagram  op  thb  Chest. 

Blank  Leaves,  suitably  ruled,  for  Visiting  List . 
Monthly  Memoranda;  Addresses  of  Patients  and 
others  ;  Addresses  of  Nurses,  their  references,  etc.  ; 
Accounts  asked  for  ;  Memoranda  of  Wants  ;  Obstet- 
ric and  Vaccination  Engagements;  Record  of  Births 


L,ouis  ciAKK,  r-r. ..  o.  i^.=,ca^c.  ux  y....^.v...,  ^ j^^  j^  Account,  etc. 

sity  Hospital,  Philadelphia.  ' 

A  NUMBER  OF  IMPROVEMENTS  and  additions  have  been  made  to  the 
reading  matter  in  the  first  part.  This  has  been  done,  however,  without  increasing 
the  number  of  pages.  Great  care  has  been  taken  in  selecting  the  leather  for  the 
covers  and  in  each  detail  of  manufacture. 


For  25 

Patients 

weekly. 

Tucks,  p( 

3ckets  a 

nd  Pencil, 

Si.oo 

^0 

75 

100 

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If 

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i« 

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II 

1.25 
1.50 
2.00 

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2  Vols      JJan.  tojunel 
2  vols.     1  July  to  Dec.  j 

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11 

2.50 

100 

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K 

«  TT-^io      f  Jan.  to  June  1 
2^°^^-     {July  to  Dec.} 

II 

11 

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3.00 

INTERLEAVED   EDITION. 

For  25 

Patients 

weekly. 

Il 

iterleaved, 

tucks  and  Pencil, 

1-25 

50 
50 

<i 

It 

2  Vols      J  Jan.  to  June' 
2  vols.     1  July  to  Dec. 

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PERPETUAL  EDITION,  without  Dates. 
?an  be  commenced  at  any  time,  and  used  until  full.     Similar  in  style,  con- 
tents and  arrangement  to  the  regular  edition. 
No.  1.     Containing  space  for  over  1300  names,  with  blank  page  opposite  each 

Visiting  List  page.     Bound  in  Red  Leather  cover,  with  Pocket  and  Pencil,    $1.25 
No.  2.    Containing  space  for  2600  names,   with  blank  page  opposite  each 

Visiting  List  page.     Bound  like  No.  i,  with  Pocket  and  Pencil,  .     .      .      .      1.50 
These  lists,  without  dates,  are  particularly  useful  to  young  physicians  unable  to 
estimate  the  number  of  patients  they  may  have  during  the  first  years  of  Practice,  and 
to  physicians  in  localities  where  epidemics  occur  frequently. 

"  For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  by  none  in  the  market." — N.  Y. 
Medical  Record. 

"  The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published."— 
Canada  Medical  and  Surgi'cal  Jnurnal. 

After  all  the  trials  made,  there  are  none  superior  to  it." — Gaiilard's  Medical  Journal. 

•  •  R     ^*i  °^"^°'"*=  Standard."— Southern  Clinic. 

<<  Tf^-^"    .  ^^  '^^  seasons  comes  this  old  favorite." — Michigan  Medical  New.^. 

,,  If  '*  quite  convenient  for  the  pocket,  and  possesses  every  desirable  quality." — Medical  Herald, 

"«  w  ^"""^^  popular  Visiting  List  extant."— .5«^«/<?  Medical  and  Surgical  Journal. 
We  have  used  it  for  years,  and  do  not  hesitate  to  pronounce  it  equal,  if  not  superior,  to  any." — Southern  Clinie, 

"  This  Visiting  List  is  too  well  known  to  require  either  description  or  commendation  from  us." — Cincinnati 
Medical  News. 

P.  BLAKISTON,  SON  &  CO.,  Publishers,  loia  Walnut  Street,  Philadelphia, 
g^*  Large  Stock  of  Physicians    Ledgers  of  Various  Kinds-^^g 


r 


COLUMBIA  UMITY  LIBRARIES  (hsi.stx) 

RG  104  .D67  1887  C  1 

^^^'^mmr'fyM,f^°'°^'cal  operations. 


2002355841 


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